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Practice comment

''Nurses and doctors must stop acting like a divorced couple''


At times, the way doctors and nurses work together on general wards can feel like a divorced couple who are no longer speaking

In a family it is the children who are affected when parents don’t communicate. In healthcare it is our patients and our personal job satisfaction that suffers.

Surgeon and journalist Atul Gawande, in his book Better urges health professionals to “Stop moaning, do something and count”. I had been moaning about ineffective interdisciplinary working on my ward rounds for years, harking back to the good old days when there was always a nurse present. The nurse knew about all the patients, was an active participant and a respected team member. So in April 2009, on my consultant-led ward rounds, we started to count the number of times we received a briefing from a nurse before the patient’s clinical review, the presence of a nurse during the review and, if a nurse was not present, whether we could find one to report back to.

Since April 2009, I have led 348 routine rounds, reviewing 5,175 cases. We have had a nurse briefing before seeing patients in only 20% of these cases and a nurse present at the bedside with only 52% of patients - and the rate is falling. In 16% of these cases we were unable to find a nurse to report to.

Nurse participation in rounds has been disappointing. There is poor understanding of what is wrong with patients and little pro-active contribution of relevant information. When I ask junior doctors to lead the reviews, they often do not even acknowledge the presence of a nurse.

Reduced effectiveness and efficiency in care, risks to patient safety, reduced patient satisfaction, and less job satisfaction are the results of this failure in interprofessional working.

We simply do not have enough nurses, healthcare assistants and ward clerks to care for the majority of our inpatients who are highly dependent, frail and old.

On our side, doctors often schedule simultaneous rounds making it unreasonable to expect a nurse to be on each ward round. We are often late in starting and may not even announce our arrival.

Between us we have allowed a generation of doctors and nurses to develop who have not seen cooperative interdisciplinary working on rounds, and as a consequence of this do not know how to talk effectively and professionally to the patient’s advantage.

The work of our team in Worthing Hospital in “stopping moaning, doing something and counting” resulted in the joint Royal College of Physicians and Royal College of Nursing (2012) recommendations on best practice for ward rounds. The challenge now is to identify and overcome the obstacles to interdisciplinary communications so our patients get the best ongoing care, and we can go home satisfied. It is time to end the great divorce and get back together for our patients’ sake.

Gordon Caldwell is consultant physician at Worthing Hospital.

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Readers' comments (11)

  • Interesting article re: ward rounds.
    I've been in the NHS for over 20 years, and in the early days the Ward Sisters used to do all the rounds then get back to the nurses to inform us of plans & developments with our patients. The Ward Sisters then knew all the patients, she did all the paper work for discharge etc, and we got help &, advice from her. The doctors knew exactly who to speak to about any patient. The Sisters spoke to the relatives so we nurses can get on with our work.
    The system now has changed to the nurse in charge of her/his lot has to do everything for their patients with no help from the Ward Sisters or Ward Managers as they call themselves. They do not go near the patients.
    The work load for the ground nurses is heavy and a lot, especially when the carers work has to be checked and supervised.
    Nurses have no choice but to keep doing the work and not stopping for ward round with doctors, as no one else steps in to help them, and with all the talk about when things are not done blame the nurses looking after the patient(s), well what can one expect.
    Ward Sisters spend a lot of time doing work that can be given to a ward clerk to do in much less time.

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  • Gorden

    Well said and well observed!

    My advise schedule your rounds and begin to insisted on a knowledgeable nurse presence!

    Dont be late 1

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  • Well-balanced article, that does not try to apportion blame but notes issues with changes on the wards, & scheduling of the ward rounds.
    In my experience, the interdisciplinary working/respect between Drs/Nurses has improved in my 15yrs in the profession. However, as Gordon Caldwell says, the systems have changed so that e.g. nurses are unable to free themselves up for ward rounds. The knock on effects both on the knowledge of the patient & any concerns (as in article) during the round, but also the number of times Drs are then interrupted later in the day with queries make the nurse time 'saved' by not attending ward rounds in my opinion well and truly a false economy.

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  • Anon 20/7 10:51
    No I am not moaning or blaming every one else.
    I have stopped for ward round with the doctors and when I get back to my patients I had tripple amount of work to do. Carers I work with when left to get on with the work just could not cope well enough, important patients' observations were not done.
    With the quality of Carers one has to work with one has to supervise and work alongside them a lot of the time.
    Only a couple of days ago a nurse was late but instead of the ward sister stepping in to help she asked another nurse with a full compliment of her own patients to take on the other patients as well, untill the nurse comes in. The sister was not busy at all and did not seem to have any thing specific to do at the time.
    Day after day I see poor management decisions being made.
    I am very vocal and I am one of those few nurse who is very active in trying to make a change.
    The whole strategy of staffing, timing of ward round, work distribution and ward management need to be looked into. It is very important for a nurse to be at the ward round. I mention ealier that the ward sisters used to do all the rounds. However, if there is a good cover for the nurses while they are doing the rounds then good.
    Nurses tend not to be able to do the rounds at this time as they are leaving their patients without proper supervision. Ward rounds can take a long time, its is not just 15 minutes.

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  • we found it worked well when each nurse did the part of the round concerning her own patients so she was constantly present on the ward and knew them best. at the end of the shift we all then had a report to discuss any changes.

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  • Anonymous | 22-Jul-2013 9:31 am

    There you go. Moaning again!! You don't even realise it do you?

    Here's a question. What are you have you done/are you going to do about it??

    I'll bet you the answer is either nothing or very little.

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  • I am not divorcing my doctor. I adore him, admire him, love him to bits and worship the very ground he treads!

    on the serious side an excellent article on a very important topic.

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  • Anon 22/7 10:35
    Don't put money on your bet you'll lose it all.
    It is important to bring in as much facts as possible on the table, also any problems encountered and reasons one feel that one has, why proper ward rounds with nurses whatever grade is not being done.
    Nurses play a vital role in ward rounds so we must get this back on track.
    To get a solution the more factual data that is available the better the chance of solving the problem. Dont dismiss wild cards that are factual as sometimes they are the missing link in solving a problem.
    Anon 10:35 I am sorry for any misunderstandings.

    Back to the heading,
    I am happy to say on the ward I work on doctors & nurses have a good working relationship.

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