239 MEDICAL EDUCATION 1998, 32, 239±243 Ó 1998 Blackwell Science Ltd

Structuring ward rounds for learning: can opportunities

be created?

Paula Stanley
School of Education, University of Cambridge, UK

impact on the time available to train junior doctors.

SUMMARY
One estimate suggests that, for surgeons, the time
This paper explores the ways in which ward rounds can available to train has been reduced by almost two-
be conducted to maximize educational opportunities, thirds, from 13 years at over 100 h per week, to 8 years
as part of a project to improve the effectiveness of on- at 56 h per week (Bulstrode & Hunt 1997). Providing
the-job training (OJT) for hospital doctors. Ninety training to the same, or to more demanding, levels over
ward rounds taken by 24 trainers in the Anglia region a considerably shorter period of time represents a sig-
were observed. Each observation produced a note of the ni®cant challenge.
ward round's structure and routines and of the contri- This challenge exists in a climate of rising work
butions made to it by trainers and trainees. Teaching intensity levels (Bulstrode & Hunt 1997) and ever-in-
was a feature of all ward rounds and different types of creasing demands by patients, purchasers and managers
round were valued for different reasons. A range of (Royal College of Physicians 1996), which has resulted
ward round structures was observed and, within each, a in an `increase in the con¯ict between service provision,
range of routines for conducting the round. Ward experience and training' (Bulstrode & Holsgrove 1996).
round structures fell into four categories, with almost Reducing the tension between these demands requires
three-quarters of trainers making no use of either pre- them to build upon, rather than compete with, one
or post-ward round meetings. Where such meetings another. `Service work must complement training
took place, however, opportunities for OJT were cre- rather than interfere with it' (Committee of Postgrad-
ated and, in some cases, optimized through routines to uate Medical Deans 1995) and theoretical teaching
encourage trainee contributions. Discussion time away must be integrated with practical work (Calman 1993).
from patients structured into ward rounds enabled For trainers, the effective integration of service,
trainers and trainees to take advantage of many op- experience and training is essential if training is to be
portunities to learn from service. Although unplanned improved with no signi®cant impact upon the valuable
and unsystematic opportunities for OJT do arise, far resource of time. For trainees, effective integration is
more reliable are those created through systematic vital if they are to maximize the learning opportunities
planning and preparation. Trainers have choices to available to them and if they are to learn as much as
make about how they conduct ward rounds and by possible from service. Such integration is the art of fus-
choosing to make use of pre- and/or post-ward round ional on-the-job training (OJT) (Hargreaves et al. 1997).
sessions, valuable opportunities for OJT can be created. This paper reports on some of the ®ndings of a re-
search and development project to improve the effec-
tiveness of OJT for hospital doctors. In particular, it
Keywords focuses on the ways in which ward rounds in medical
Consultation; *education, medical, undergraduate; specialties are structured and conducted and the im-
England; hospital medical staff, *education; patients' plications of the range and diversity of practices for the
rooms; teaching, *methods development of OJT on ward rounds.

INTRODUCTION BACKGROUND
The combination of the Calman reforms (Department Informal training acquired through service is an im-
of Health 1993) and New Deal (National Health Ser- portant part of a junior doctor's training. In a pilot
vice Medical Executive 1994) has had a signi®cant survey of senior house of®cers (SHOs) in four hospitals,

Correspondence: Miss Paula Stanley, Training of Doctors in Hospitals Project, University of Cambridge School of Education, 17 Trumpington
Street, Cambridge CB2 1QA, UK
240 ME D I C A L ED U C AT I ON 1998, 32, 239±243 Ó 1998 Blackwell Science Ltd

nearly three-quarters of respondents said that teaching R E S U L T S A N D D I S C U SS I O N

and learning arose mainly in informal ways (Booth et al.
The traditional distinction between teaching and busi-
1995). With regard to ward rounds, Grant et al. (1989)
ness rounds was not apparent. Trainers and trainees
report that of the 608 doctors they surveyed, 58% of
regarded teaching as a feature of all rounds, whether led
SHOs and 84% of consultants regarded the consultant-
by a consultant or a fellow trainee and whether the
led ward round as a learning method upon which most
round was routine or taking place during, or after, a
SHOs rely. Between 41% and 51% also regarded ward
period on-take. Teaching was therefore not con®ned to
round teaching with a senior registrar or registrar as a
`teaching rounds', but also to `business rounds'. In-
learning method upon which they rely most.
deed, rounds labelled as `teaching rounds' tended not
The reliance placed upon ward rounds as settings for
to feature prominently, as they were more likely to be
learning (also noted in the United States by Weinholtz
organized for medical students than for junior doctors.
& Edwards (1992) in their manual of teaching ward
While all types of round were regarded as venues for
rounds) render them important in the strategy to im-
teaching and learning, they were valued for different
prove the effectiveness of learning through service. El-
reasons. In particular, post-take rounds provided op-
liot & Hickam (1993) note of the UK that `the structure
portunities to review diagnostic and management skills
of medical ward rounds re¯ects tradition, rather than
with a senior doctor; rounds led by registrars were
experimentation with the impact of different structures
valued because of their approachability, their closeness
on educational and patient care objectives'. They con-
in terms of seniority and their high levels of clinical
clude that there is a need for new educational formats
experience and skill; and consultant-led rounds pro-
and teacher development programmes.
vided direct access to `fountains of knowledge'. Dif-
New ward round formats serving educational pur-
ferent types of ward round therefore offer different
poses require, as a ®rst step, an understanding of the
learning opportunities for trainees.
ways that educational opportunities arise from the
various ward round structures and routines. It is this
understanding to which this paper seeks to contribute. Ward round structures
Ward rounds were categorized into four types (Hargr-
eaves et al. 1997):
METHODS (1) ward round only (teaching or business);
Ward rounds taken by trainers in three medical spe- (2) pre-ward round meeting followed by the ward
cialties (general medicine, care of the elderly, paediat- round;
rics/special care baby units) in four hospitals in the (3) ward round followed-up with a post-ward round
Anglia region were observed between February 1995 meeting; and
and June 1996. Twenty-four trainers (two-thirds of (4) pre-ward round meeting, ward round, followed-
consultant grade, one-third of specialist registrar grade up with a post-ward round meeting.
(SpR)) were observed on a total of 90 ward rounds. Of the 24 trainers, more than two-thirds (71%)
Rounds were attended by registrars, SHOs, house of- conducted type 1 rounds only, with two trainers (8%)
®cers (HOs) and, in some cases, medical students. routinely undertaking type 2 rounds, one (4%) of type 4
They took place either during routine service work or rounds and the remaining four (17%) varying their
during or immediately after a period on-take. practice between the different types (two making use of
An observational note of each ward round was taken, types 1 and 2; one making use of types 1 and 3; and
including: another of types 1, 2 and 3). Variations in the structures
 how each was structured; adopted were by individual trainer preference rather
 the routines employed, and than by specialty. For example, in one specialty, one
 the contributions made by trainers and trainees. consultant conducted a pre-ward round meeting rou-
tinely, while another made use of a post-ward round
Follow-up open questions were asked where possible to meeting.
clarify understanding about the event witnessed.
On the basis of the observational notes ward rounds
The pre- and post-ward round meeting
were categorized according to their structures. Exam-
ples of ward round routines and of trainer and trainee Pre- and post-ward round meetings, where held, dif-
perceptions of rounds were extracted from the notes, fered considerably in their aim, their frequency, the
from which patterns and themes were identi®ed. range of staff attending and the routines established for

Structuring ward rounds for learning P Stanley

241 ME D I C A L ED U C AT I ON 1998, 32, 239±243 Ó 1998 Blackwell Science Ltd

presenting and discussing cases. For example, in one had arisen. Discussions observed were interactive and
team a pre-ward round session took place once a week wide-ranging and, on occasions, lengthy. A consultant
in a seminar room. Its aims included the review of all in a different specialty and hospital managed a more
patients, brie®ng the team on-call and informing and/or formal session, attended by nursing staff and social
seeking the input of other medical professionals, such workers. Its aim was to brief other professionals about
as dieticians, community nurses and psychologists. As patients and trainee contributions were limited.
many specialty trainers and trainees attended as possi- Pre- and post-ward round sessions are thus capable
ble and the session generally lasted between 60 and of providing trainees with many opportunities for
90 min. Discussion generally followed a pattern: learning from service. By structuring discussion time
into ward rounds away from patients' bedsides, trainees
(1) the SHO presented a brief case history, and de-
can take advantage of many opportunities to learn from
scribed symptoms and treatment given so far;
service work. These opportunities can be maximized by
(2) consultants (usually) added information and
structuring sessions in a way that invites trainee par-
discussed outstanding problems and action steps, con-
ticipation.
tributions from nurses and other professionals were
In practice, few trainers make regular use of pre- and/
requested;
or post-ward round sessions, despite their value for
(3) decisions were taken, primarily by consultants,
learning. In addition, the diversity of the routines render
and
some sessions more effective for OJT than others.
(4) the SHO noted decisions in the ®le and pro-
ceeded to the next case.
The ward round
In contrast, a different team conducted a pre-ward
round meeting before every round, in the consultant's As with pre- and post-ward round sessions, ward
own of®ce away from the ward. It was attended by rounds were also conducted in different ways. For ex-
doctors only and all patients to be seen on the ward ample, discussions about patients took place either at
were discussed. The meetings generally followed this the bedside or around trolley notes in a corridor, or
pattern: trainers took decisions with or without seeking the
opinions of trainees. Each variation inevitably has im-
(1) SHO, registrar (R) or consultant (C) presents
plications for OJT.
patient history and presenting symptoms;
Where a pre-ward round session took place, there
(2) if SHO, R or C asks factual information ques-
was generally less need for discussion and debate on the
tions;
ward round itself. As a result, some rounds took a
(3) all three discuss the case;
service delivery or a patient-relations focus and were
(4) C asks SHO and R for opinions;
completed in less time, thus compensating for some of
(5) all discuss possible diagnoses and agree a course
the time devoted to the earlier session.
of action.
Observations of the various ward round practices
Each session type presented unique opportunities for suggest that the location and timing of ward round
OJT. For example, in the former the opportunities were discussions is important in determining the opportu-
perceived to be learning about management from a nities available for OJT. Formal discussion times
range of professionals and in the latter the opportunities structured into ward rounds, although not commonly
to learn were created by providing space to offer opin- used, enabled trainers and trainees to build upon more
ions, seek explanations and ask questions. The exam- usual opportunistic discussions. For example, in one
ples also re¯ect a variation in the level of contribution team, a 10-min period was structured into one ward
expected from trainees. In the former, trainees took a round each week for trainees to raise any issues from
predominantly passive role of observer and record- the round they wished to discuss. Trainees willingly
keeper and, as a result, learning opportunities tended to shared the responsibility for raising issues. In another
be trainer-determined. In the latter, trainees took a team, trainers and trainees introduced a `3-minute
more active role, creating opportunities to meet their round-up', where trainers routinely offered a period of
learning needs. 3 minutes to trainees in which they could raise any is-
As with pre-ward round sessions, the structure and sues they wished. By dedicating time to teaching and
practice adopted in post-ward round sessions varied learning, opportunities were created in an environment
considerably. For example, with one consultant it was controlled by the participants (i.e. in private, out of the
very informal, taking place over coffee at the end of the hearing of patients and relatives), and thus conducive to
round where trainer and trainees discussed issues which learning.

Structuring ward rounds for learning P Stanley

242 ME D I C A L ED U C AT I ON 1998, 32, 239±243 Ó 1998 Blackwell Science Ltd

D I SC U S S I O N  identifying relevant teaching and learning material

(e.g. patients, conditions) at the start of each round
Teaching and learning was an implicit part of all ward
to shape the OJT agenda;
rounds observed. No teams agreed explicitly among
 participating in the round fully by offering opinions
themselves that a particular training focus would be
on patient diagnosis and management;
taken, nor were there many rounds in which dedicated
 asking questions to ®ll information gaps or correct
time was aside for trainees to raise issues of concern.
erroneous thinking;
Teaching was largely opportunistic, arising from dis-
 contributing to agreement about a course of action;
cussions about patients where circumstances and time
and
permitted. Where individual enthusiasm did not drive
 asking for feedback.
the teaching, there was a danger that the teaching
element was squeezed out by service pressures.
Although the immediacy of service demands did, on
occasions, make such a focus entirely necessary, with CONCLUSIONS
the absence of clear teaching and learning objectives Implications for effective on-the-job training
and expectations the teaching element was often dif®-
cult to sustain. The wide variations in the structures and practices of
The variations in ward round structures resulted in ward round delivery have considerable impact upon
considerable variance in the opportunities available for their value for teaching and learning. In turn, this
OJT. As the examples demonstrate, both pre- and post- means that there is considerable scope for development.
ward round discussions can be used to create oppor- Although unplanned and unsystematic opportunities
tunities for OJT. By structuring discussion time into for OJT do arise, far more reliable and effective are
ward rounds, in a place out of the hearing of patients those opportunities created through systematic plan-
and relatives, trainers and trainees can take full ning and preparation.
advantage of opportunities for: Trainers have choices to make about how they
structure and conduct ward rounds. By choosing to
make use of pre- and/or post-ward round sessions,
 full and frank discussion of each patient's condition
valuable opportunities for OJT can be created. They
and circumstances as it affects management;
also enable trainers to teach in explicit and direct ways
 questioning by trainers, enabling trainees to offer
by, for example, providing immediate feedback where
answers in private without embarrassment;
trainees make an error. Discussions of this nature, if
 open correction of unwise or erroneous answers and
conducted in front of patients, may lead to unnecessary
suggestions from trainees;
concern and to undermining patient con®dence in the
 debating the advantages and disadvantages of vari-
medical team.
ous diagnostic and management options;
To develop OJT on ward rounds trainers must
 analysing the degree of success of treatment and
address not only whether a pre- or post-ward round
management;
session would create additional opportunities for on-
 comparing the current case with similar current or
the-job training, but also how such sessions could be
past cases;
planned and structured and what practices employed to
 deciding on the next steps in patient management,
maximize those opportunities.
after discussing the merits of all options;
 discussing what needs to be done in relation to each
patient, and
A C K N O W L E D G E M E N TS
 selecting patients, conditions or topics to form the
focus of the teaching and learning on round itself. I thank colleagues in the School of Education, Professor
David Hargreaves, Dr Martin Booth, Howard Bradley,
Structured discussion time, however, by no means Dr Geoff Southworth and Joy Anderson for their help
guarantees that trainees' learning needs will be met; and advice in developing this paper.
decisions must also be made about the way sessions are
to be conducted. In the absence of explicit teaching and
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