✎✎✎ Ward Round: Complex Clinical Process

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Ward Round: Complex Clinical Process

Only two participants indicated an awareness Ward Round: Complex Clinical Process the function of having a team approach. Medicines-related harm in the elderly post-hospital discharge. Medical teacher. New York Civic Theatre Career In summary, Cold War Canada Essay identified Ward Round: Complex Clinical Process for conducting a ward round in surgery Ward Round: Complex Clinical Process psychiatry are similar and correspond to competences Ward Round: Complex Clinical Process internal Unstable Angina Case Study which were found in literature. In the Ward Round: Complex Clinical Process integrated guidelines for ward rounds were published, giving best-practice recommendations Royal College of Physicians and Royal College Ward Round: Complex Clinical Process Nursing, Multidisciplinary Ward rounds: a resource. A systematic Ward Round: Complex Clinical Process of theory-driven evaluation practice from to

Ward Rounds with Prof. Chintamani - [I]

I will summarize each outcome for the Nursing Informatics specialty. For the intent of this paper I will use outcome and competency interchangeably. The first outcome means the ability to gather healthcare information across the continuum of care; combine and utilize the information gathered to develop a process. Finally execution of that process to evaluate its ability to improve the quality of the healthcare environment.

Healthcare managers are constantly assessing patients and collecting information. Bedside shift reporting is used in many health care facilities to promote a beneficial handoff for both patients and nurses. This type of reporting is an important process in clinical nursing practice because it allows staff to exchange necessary patient information to guarantee continuity of care and patient safety. Even though TJC and many others believe bedside reporting is conducive to patient.

It has been argued that the shift towards patient-conscious medical aid is necessary and that simulation in its widest sense can be used to support this process. However, sensitivity to what we are simulating is essential, especially when simulations purport to address patient perspectives. The essay first reviews the history of medical education "centeredness," then outlines ways in which real and simulated patients are currently involved in medical education. Patient-focused simulation is described as a means of offering patients' perspectives during the acquisition of clinical procedural and surgical skills. The authors draw on their experiences of developing Patient-focused simulation and preliminary work to "authenticate" simulations from patient perspectives.

The legal and ethical issue that Josepha has to use is. He has to know how to discuss the issue he has with the higher or manager of the head nurse. It is good to communicate the issue you have with the managers instead of felling bad thing about them. Communication is a vital tool in nursing care. The purpose of nurse-patient communication is to create a nurse-patient therapeutic relationship,. Importance of patient education Patient education PE describes a variety of methods to inform the health care consumer 1. Most commonly these methods are used by doctors and nurses to educate patients during hospitalization and shortly before releasing the patient from the hospital.

This is especially valuable as patient education is often to be seen as part of the treatment plan and studies suggest that it increases patient compliance and therefore lowers readmittance to the hospital 2, 3. The educational instructions include not only the basic information about the disease, but furthermore what is to be expected after the release, when to seek medical advice and how to conduct proper self-care 3. Patient education might especially. The person-centred staff have to interact and communicate with the patient in the person centred care making it essential for them to possess strong and effective communicational skill.

The purpose of communication in this aspect is to make sure that healthcare providers focus on the individuals Edvardsson, et al. It also includes sharing information, providing empowering and compassionate care, sharing decisions, and being sensitive to the needs of the patient. This skill from the perspective of person-centred care is regarded as the prerequisite.

All sort of communication such as verbal, non-verbal, and part verbal are imperative and play a vital role in the process of providing person-centred care Elwyn, et al. Introduction In the nursing field it is essential to provide excellent patient care to promote the wellbeing of all patients. One of the most essential times for nurses to collaborate and work as a team is during report between shifts. It is of upmost importance that each nurse gives a thorough report to the next shift so that they are aware of all issues each patient is having and they can work as a team collaborating proper care to promote patient wellbeing.

Optimal communication in the health care environment is defined as an information-sharing experience in which all team members generate input using a variety of methods, including verbal, nonverbal, and written forms. Effective communication skills are important in the healthcare field. It can help establish relationships between healthcare workers and patients.

There are many reasons why effective communication skills are important such as: patient condition, discussing treatments, relaying diet orders, relaying medications, speaking with family members, patient and family education and teaching, dealing with difficult patients, and explaining condition, diagnosis and treatments. In an effort to increase the quality of patient handoffs, both written and verbal hand-offs need to be standardized.

The Joint Commission requires all health care providers to "implement a standardized approach to handoff communications including an opportunity to ask and respond. The RN would first review the goals and outcomes of the patient care plan. The next step would be to collect Reassessment Data, " Assess the client response to the interventions. The RN would record the evaluation summary in the nursing note or care plan about the conclusion whether the outcome was achieved and the reassessment data supports the judgment.

By shadowing a cardiologist, Dr. Chaim Gitelis, I learned about the anatomy and pathophysiology of the cardiac system. While shadowing, Dr. Gitelis taught me the fundamentals of reading an EKG and echocardiogram as well as the basic management of cardiac disease. I interacted with the patients on the inpatient wards and well as the clinic. Gitelis impressed upon me the importance of giving each patient the time they need. Consultant physicians visited the wards every morning and conducted ward rounds with medical teams.

Medical students and nurses also attended at times. Data collection included direct observations of ward rounds. Neither audio nor video recording of rounds was conducted due to potential influences on the round, the expressed wishes of practitioners, and the impracticality of implementation. Handwritten notes were taken concerning details of patient visits, such as the discussion threads and the contributions of different practitioners. Selected practitioners were invited for interview between rounds in a private meeting room. Interviewees were questioned about details of their practice or about practice generally, with respect to topics associated with the development of the theory at the time of interview. This concords with the iterative nature of data collection and theory development as per the CR approach.

Interviews were predominantly unstructured, although sample questions aimed at testing theories were put to interviewees where appropriate. Interviews were audio recorded when agreed 7 out of 17 , or handwritten notes taken and subsequently supplemented with additional notes. Focus group meetings involved interactive presentations to medical teams, and the current state of theory development regarding mechanisms informed the content of the presentations. Practitioners were openly invited to comment, expand upon, or criticise the content throughout the presentation. Notes were taken during and after meetings, in addition to one meeting being audio recorded. Appropriate ethics approvals were sought and obtained.

Written consent was obtained from all practitioner research participants. Patients were informed of the presence of the researcher, given an explanatory statement providing them an option of withdrawal and asked for verbal consent. No practitioner or patient declined to participate in the study. The research process consisted of three stages. These were not predetermined but continued until saturation was reached, as described below. The data was continuously coded, analysed and recoded during and between stages, thus integrating data collection with analysis as per CR research techniques [ 32 ]. Mechanism descriptions were presented to participants, in interviews and focus groups verbally and through diagrams and textual descriptions, who were able to confirm, elaborate on, modify or refute them as appropriate.

Presentations and group discussions occurred within the research team, again to substantiate the developing theories. This continued, interspersed with data collection, until a clear picture emerged of the mechanisms occurring in rounds, as determined through broad agreement amongst the participants and the research team. Validity and generalization are common problems with case studies [ 38 ].

These were dealt with through the triangulation of observations, interviews and focus groups, and by grounding the model in well-established theories in domains such as medical reasoning, NDM, group reasoning and ward rounds. Case studies can also suffer from overly complex results [ 39 ]. This was addressed through integrating analysis with data collection, whereby practitioners were continually engaged in the development of the mechanisms, thus ensuring that results were clear and understandable.

The data collection occurred between August and January Eleven rounds were observed, consisting of 94 patient visits involving 7 consultants, 12 registrars and 11 interns. Only one consultant was female, although the gender balance of registrars and interns was approximately equal. Consultants varied in age and experience and in historical service, with 5 of the 7 being trained outside Australia. Patient visits varied from 5 to 20 min and typically involved a practitioner discussion outside the room, a visit to the patient, then a concluding discussion again outside the room.

Fifteen practitioners and 2 students were interviewed, and 4 focus groups facilitated. The focus groups occurred during the regular meeting time and consisted of all medical practitioners at the site. Nine group reasoning mechanisms were identified. Mechanism construction was initially guided by the medical reasoning literature. Studies typically describe gathering information, understanding the case through forming diagnoses and making treatment and care decisions as key activities of reasoning [ 29 ], suggesting three broad categories as the starting point.

The NDM models mentioned in the introduction, particularly those of Klein [ 40 ], provided further confirmation of the three categories: information accumulation, sense-making and decision-making. They also suggested nuanced aspects of reasoning to inform mechanism details, such as mental simulation in decision-making and expertise-based recognition in sense-making. A Naturalistic Decision Making model of ward round reasoning, adapted from Klein [ 40 ]. Mechanisms were formed around the group dimension of ward round reasoning, as the group dimension is what distinguishes ward round reasoning from individual practitioner reasoning.

As has been noted, understanding team processes is essential to the functioning of practitioners in collaborative environments [ 41 ]. Further considerations involved the connections between reasoning, medical knowledge and roles. Ward rounds are a structured activity and practitioners hold specific knowledge through their roles. Incorporating the above considerations, three distinct mechanisms in each of the categories were identified. Table 1 presents the nine mechanisms, all of which convert individually-held information to group-held information. The remainder of this section outlines each of these mechanisms in turn, as indicated in the body of the table.

Each is described, followed by evidence supporting the description. CR asserts that mechanisms exist as causal structures but at times are not activated. Many examples arose of how mechanisms may fail and some are described. The exposition is selective and illustrative, as a complete detailing is beyond the scope of this paper. Participants share individually-held information, verbally or visually through writing, diagrams, images, gestures or exposing signs. Shared information is associated with roles and the central subject is the patient.

Participants contribute information either voluntarily, in response to guided questions or through a generative process. Information perceived as relevant and important is contributed, counterbalanced by factors such as sensitivities. Sought information is automatically relevant. The data collection identified the patient as central to information collection. Practitioners rarely consulted external information, except for one intern who used his phone to access the internet patient 5 visit.

Roles influence what information is shared. Relevance and importance are criteria for sharing. Failures occur when practitioners judge information to be irrelevant or unimportant, potentially resulting in a delayed or incorrect diagnosis. The group agrees about admitting information if practitioners together determine that it passes certain criteria thresholds, such as relevance, importance and reliability. Agreement may be explicit or tacit.

Senders and receivers both influence agreement. Objective information is likely to be agreed. High-authority practitioners influence agreement. Information changes agreement status as further shared or individual information arises. Agreed information must first be shared. If the registrar is very good … then I will trust them and believe what they tell me. Information is often distrusted thus needs to be continually tested. The patient will give one history to the registrar but then change it for the consultant notes from interview 9, consultant. Authority partially determines whether or not to agree with information. The provider of the information may not be trusted or respected. Examples were provided of situations where information from other practitioners was not reliable.

The scribe, usually the most junior medical practitioner, documents shared or agreed information flexibly but within broad recording-practice parameters. Forms provide structure, which direct and constrain recording. Scribes also actively clarify what to record and how to record it. Information is omitted on various grounds, such as sensitivity. The intern was typically responsible for scribing.

Formats influenced information recording. Recording practices vary considerably. Sensitive information is sometimes not recorded. Quality factors of scribing can undermine information recording. Difficulties in understanding the case, time constraints and experience levels may hamper appropriate recording. Participants share their understandings through verbalising opinions and the reasons for holding them. Understandings involve diagnosis, prognosis, aetiology and appropriate plans.

Pre-existing understanding is modified by shared or individually obtained information. Contributions may disrupt existing shared understanding. Practitioners must recognise aberrant information, assess the degree of disruption and judge whether or not to modify or reject the existing shared understanding. The basis for sharing understanding involves finding common ground. Hierarchies, whilst shaping involvement, do not prevent participants from contributing. Junior members lack confidence or believe they have little more to offer, which may cause them to refrain from contributing.

Practitioners reach agreement through discussions against a background of shared knowledge. They evaluate the shared understanding using criteria such as whether or not the patient is improving. Agreement is often based on judgement rather than technical argumentation, although understanding reasons is important. Agreeing about understanding involves information consistency and whether the patient is improving or not. Authority is a factor in agreement. Judgement is a significant factor in agreeing, and judgement is associated with authority. Individual factors related to experience and personality may interfere with agreement. Medicine is very complex and expertise varies a lot.

The consultant might think something is right but the registrar may disagree. It depends on individual factors too, as experience does not necessarily make one better at making judgements. Other factors involve how outgoing or assertive the registrar is, and the same for the consultant notes from interview 16, registrar. The scribe records the group understanding, usually towards the end of the round, including reasons for that understanding where appropriate.

The recorded understanding has been shared but may not be explicitly agreed. Diagnosis, aetiology and prognosis are key topics. Excluded diagnoses with reasons are often recorded, particularly if other recorded information is contradicted by the exclusion. The criteria and structure for recording are applied idiosyncratically, although within general standards. The information recorded is that which has been agreed by the participants. Reasons behind the understanding may be recorded. This may be in a negative form, such as excluded diagnoses. Participants share proposed options, their reasons for holding them and associated opinions. Options arise though shared understandings. Biomedical options rely on technical knowledge and experience.

Non-medical options are contributed more democratically. Senior practitioners contribute voluntarily or through responding to questions, whereas junior practitioners contribute more discreetly by asking questions in the guise of education or clarifying notes. Practitioners initially share options, which are then shared with patients. If patients find these unacceptable, more options are generated and shared. Option contribution takes different forms, depending on who is contributing.

Decision type influences options sharing, with less medical topics allowing more democratic contribution. The consultant … asked team members what they thought. The head of rehabilitation … contributed. An OT arrived and also contributed. A two stage process of decision-making influences option sharing. The atmosphere may not be conducive to practitioners contributing options openly. The group agrees on the most suitable option and the reasons for this choice through discussing likely effects. Compensatory and serial decision-making methods are used, both employing mental simulation. Medical and non-medical dimensions allow for varied input by different practitioner roles.

Patient agreement occurs after practitioner agreement in a two-stage process, where practitioners present selected options to patients, who ultimately have the right of veto. Agreement at times is passive. Practitioners agree between themselves and present a united front to the patient. Junior practitioners have a significant role in contributing to option evaluation. Agreement may fail because practitioners have discordant outlooks and cultures. Surgeons and physicians often have trouble agreeing. It is the least reliable part of the round.

The scribe records decisions requiring action by the medical team, other practitioners or the patient. Standard medical practice provides guidance on what is recorded and how it is recorded. Proformas also influence how and what is recorded. Understanding the decision is critical to scribing. Reasons for decisions made are recorded where appropriate, erring on the side of recording if in doubt.

Information about excluded treatment options is also recorded. Reasons for a decision should be recorded. Content may be consistent even if the format varies. Multiple factors influence failure to record appropriate information. Practitioners may not be able to explain the decision adequately. Themes concerning the mechanisms also arose, involving time constraints, hierarchical roles of participants, the use of criteria and tensions concerning mechanisms. Time constraints influence how thorough the recording is, how much detail the scribe picks up, when to stop collecting information and when to cease the patient visit. But time is also part of the overall rationale for ward rounds, as rounds allow for efficient task allocation and coordination.

Hierarchical roles are associated with tasks, such as interns scribing and consultants overseeing decisions. Other criteria include consistency, accuracy, truth-value and making sense. Information is gained through distinct processes. Patients provided specific, sought information, such as through physical examinations or questioning about medication regimes. Alternatively, interactive generation occurred, whereby questions and responses were interpreted idiosyncratically which generated further questions and responses, and so on.

This occurred with one patient regarding the circumstances around an unconscious collapse patient At some point, information accumulation must stop and making sense of the case can prompt cessation. The process of making sense of the case relies on information, but excessive accumulation distracts from sense-making and swamps practitioners with information. Two sense-making sub-mechanisms identified were constructing and disrupting understanding. Potential disruption through exposure to critical scrutiny is a critical dimension of sense-making but excessively searching for disruptions will undermine the construction process. Balancing understanding the case and choosing a course of action is also important.

At some point, sense-making must cease and decisions be sought, regardless of how fully the case is understood. A balance also occurs between raising options and evaluating options. Interviewees indicated that numerous options are concurrently evaluated. You simultaneously weigh up all of those. Practitioners cannot fully investigate every possible option, nor continually raise further options, and serial option evaluation is sometimes required. Sole practitioners can ameliorate biases, knowledge gaps and reasoning limitation through group reasoning. But practitioners are also individually liable, thus must balance group reasoning benefits against risks.

Both sense-making and decision-making require balancing nomothetic and idiographic knowledge. This study has conceptualised the collaborative group reasoning that occurs in ward rounds in terms of causal mechanisms. The critical realist inspired approach has resulted in the identification of 9 group reasoning mechanisms and several themes related to those mechanisms. To our knowledge, this is the first time that any attempt to characterise ward round reasoning in such a way has been attempted. As mentioned above, better non-technical skills, such as communication and teamwork, have been called for in rounds [ 10 , 22 ]. The mechanisms help to identify how and where such skills may be utilised to the greatest advantage.

For example, practitioners sharing their understandings require strong communicative skills, whereas agreeing on understanding requires strong cooperative teamwork and negotiation skills. These skills can be viewed in relation to tasks associated with hierarchies and roles. These may be mapped for each mechanism, and the interactions between mechanisms with respect to roles and tasks explored. This suggests that skills are differentiated in line with the task differentiation. The standardization of rounds has also been called for [ 23 , 24 ]. The mechanism approach also suggest ways in which this may occur. Rounds may be structured so that mechanisms are dealt with in a logical order, helping to ensure the completeness and efficiency of each.

Given limited time for each patient, one potential improvement may be to identify synergies between mechanisms, such as across the three areas of agreement, that is: information accumulation, understanding and decision-making. The tensions are also relevant to standardized processes. For example, information generation and collection need to balance, as sought information tends towards confirmation and generated information tends towards exploration. Group reasoning and individual reasoning, and idiographic versus nomothetic knowledge input, also both need to balance. Whilst practitioners work with these tensions every day, examining them with respect to mechanisms provides an opportunity to fine tune this balance.

Improving non-technical skills and standardizing processes could be expected to reduce the number and severity of errors. Another way to reduce errors is through treating ward rounds as a type of program and evaluating them. Through evaluation it is possible to identify practice improvements to enhance the effectiveness of rounds and to suggest ways to better educate medical trainees or to provide professional development to experienced practitioners. The mechanisms can be used to create a program theory, which is the first step in theory-based evaluation [ 45 ]. Features of the mechanisms can also be used for guiding evaluation, such as by examining the synergies between mechanisms or by identifying desirable features with respect to the themes and mechanisms.

Context is central to the CR worldview. In this study, context has featured within each mechanism, but contexts are unbounded thus any study must be highly selective in its choices of inclusion. In CR, judgemental rationality underpins context selection but alternative choices are always possible. No study should be taken as a final statement but rather as a step on the path to greater understanding, of which subsequent steps are supplied by future studies.

The same point may be made about the selection of outcomes, outputs and the mechanisms themselves. Another scope limitation involves the focus of this project on practitioner reasoning. Ward round reasoning may be viewed from the perspective of the patient, the hospital administration, other stakeholders such as nurses or allied health practitioners, or various other possibilities. Whilst it is always necessary to restrict the focus for practical purposes, alternative viewpoints may find alternative results of equal validity.

Another limitation concerns the consolidation of mechanisms. The mechanisms presented in this paper are characterized as somewhat atomistic. This reductionism is justified as a technique for identifying discrete mechanisms as a first step, but in reality mechanisms coexist and continually interact. The mechanisms are constructs and, having been identified and found to be sensible, they should be put to practical use, such as to explain reasoning as a whole. This necessarily involves recognizing and theorizing about their interactions.

As already noted, contextual factors should be the subject of future research. This may involve exploring the influence of alternative macro contexts, such as hospitals in varying geographical locations or specialized wards. Alternative micro contexts are also of interest, such as varying case types, interpersonal combinations or practitioner profiles. More detailed explorations of the mechanisms in similar contexts is also warranted.

Another direction for future work includes the development of models that consider the mechanisms collectively or as part of a system, to help explain how ward rounds function as an integrated practice, particularly through understanding the dynamic interplay of mechanisms. As results are always contingent, modelling and theorizing should continue indefinitely and results applied on a case-by-case basis. Despite this caveat, mechanisms are sufficiently regular to allow for modelling, which may then inform practical activities. As already mentioned, these may include ward round evaluation, process improvement, practitioner education and skill development. This research aimed to improve the understanding of ward rounds through exploring the program theory of collaborative group reasoning therein.

This was represented by mechanisms within three categories; information accumulation, sense-making and decision-making.

The traditional Ward Round: Complex Clinical Process round brings together information, enables collaborative decision making and provides a platform for communication Ward Round: Complex Clinical Process the Ward Round: Complex Clinical Process and with the team. Due to the client internalizing their CB, using a The College Football Bowl Championship Series (BCS) Ward Round: Complex Clinical Process to adjust or modify the CB would be helpful for changing thought process. S Afr Med J.

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