Ward rounds are a long-held, essential, aspect of hospital tradition and the delivery of patient care.Reference Nedfors, Borg and Fagerström1 They are complex clinical activities that form a pivotal point of care designed to facilitate communication between doctors, nurses and members of the multidisciplinary team (MDT) to deliver good patient care and address their concerns.Reference Lees2 They may fulfil other roles such as training, safety checking and making discharge arrangements.Reference Walton, Hogden, Johnson and Greenfield3,4 Ward rounds may be held in several different formats. Regardless of the format of ward rounds and MDT composition, the role of the medical and nursing teams is always central to the process.Reference Walton, Hogden, Johnson and Greenfield3 They have practical and cultural importance as both tool and ritual in which bedside teaching occurs, and knowledge is passed down from senior doctors to their more junior colleagues.Reference Parissopoulos, Timmins and Daly5 They remain a ubiquitous way to manage a team, facilitate a good relationship between the patient and doctor and pass news among the treatment team, the patients and their family members, in both medicine and psychiatry.4 In psychiatry, ward rounds fulfil many of the same functions as in general hospital medicine although usually occurring less frequently, often once or twice per week. Due to the complex environmental, social and clinical factors at play in psychiatry, there have been several difficulties associated with conventional ward round structure and the increasing numbers of professionals often present. These include issues with power dynamics between the consultant, staff and patients; difficulties in adequately communicating with patients that have altered mental status; and discussing intimate information with large numbers of healthcare professionals present.Reference Cappleman, Bamford, Dixon and Thomas6,Reference Labib and Brownell7 With a complex clinical intervention within a similarly complex environment, there is considerable variation in practice. There is no established gold standard in the UK as there is for internal medicine.
As with other aspects of in-patient psychiatry, ward rounds are often seen as coercive interventions within a predominantly biomedical approach.Reference Aaronson and Mouratidis8 Practitioners in various disciplines have sought to reform or refine the practice. One notable area of inspiration for rethinking what constitutes successful patient–staff interactions has been therapeutic communities. Community meetings do not provide a direct analogy to ward rounds, their scope typically being much broader and meetings much more frequent. Nonetheless, therapeutic community ideals and principles have shaped the intellectual landscape through which good practice is viewed.Reference Campling9
For such a central part of everyday in-patient psychiatric practice, there has been a modest amount of research focused on psychiatric ward rounds. This scoping review aims to look at the methods used by perspectives researchers to understand ward rounds and to identify recommendations that could help inform our practice of ward rounds in psychiatry.
Method
The review protocol was registered on the open science framework (link available on request).
The eligibility criteria were broad, to reflect the concern of the review. Studies were included if they featured discussion of psychiatric in-patient ward rounds in which patients were participants. Ward rounds did not have to be the primary focus of the research, but to constitute a key component of the research and have results described separately. For example, a paper on communication with patients that included both ward rounds and patient–nurse communication at other times, with clear distinction of when each is referred to, would be included. Both civil and forensic hospitals, or wards, were included. Acute psychiatric intensive care, specialist (for example, eating disorders or intellectual disability wards) and rehabilitation wards were included. No restrictions were made according to age, gender, diagnosis or nationality. No restriction was made for study design to consider various aspects of ward round functioning, and to allow triangulation between methods where possible. Studies were sought that addressed practical concerns, e.g. efficiency or comprehensiveness, or broader and theoretical concerns such as issues of culture, communication, group or individual psychology, power or identity as they occur during a psychiatric ward round. Included studies must be either peer-reviewed publications, research published as an editor’s letter or PhD theses.
Studies of professional discussions, handovers, board rounds or team meetings with no patient participation were not included. Studies of day hospitals and drug and alcohol rehabilitation services were excluded. Staff-facilitated community meetings or group psychotherapy in traditional in-patient settings or therapeutic communities were not included. Only English-language articles were included. Opinion pieces, editorials and editor’s letters not reporting research were not included.
The databases searched were Medline, CINAHL and ProQuest (including British Nursing Index, PsycInfo and Health Research Premium Collection). These were chosen to provide an overview of nursing, medical, psychological and allied health professional literature. The dates searched were from database inception to 13 November 2023. Reference checking was undertaken manually during the full-text screening process. Citation checking was undertaken for included studies using Crossref. Searches were limited to full-text, peer-reviewed papers and theses/dissertations. For ProQuest, search terms were limited to anywhere but full text. The search terms used were psychiatry* AND (ward round OR ‘multi-disciplinary team meeting’ OR ‘clinical team meeting’).
Search results were exported to Rayyan version 1.3.1 (Rayyan Systems Inc., Cambridge, MA, USA; https://www.rayyan.ai). Rayyan was used for algorithmic detection of duplicates, which were confirmed by manual checking with one author. Titles and abstracts were screened for inclusion by one team member using a broad approach to screen within articles. Three reviewers undertook full-text screening. All reviewers screened the same three first journal articles and discussed the results of these to provide calibration; all three reviewers then reviewed the remaining full texts independently. Differences in screening were resolved by a simple majority. The three reviewers undertook data extraction independently using the same chart. The same three papers as initially screened were also used for pilot data extraction, with minor changes and additional prompts added to the data extraction tool. Data charting was conducted using a spreadsheet. Data were initially extracted as wholesale as possible from the original papers. The authors then compared the data extracted and reduced these to common constituent parts or themes through discussion, with disagreements resolved by a simple majority.
The variables sought included each study’s definition of a ward round, theoretical basis, substantive focus, method for data collection and analysis, key findings, and recommendations for practice, as well as country, setting/speciality, participant numbers of staff and patients and participant demographics. Due to the heterogeneity of the study designs included, and the emphasis of the review on understanding the scope of the literature in a broad sense, no standardised tool for critical appraisal of the studies could be used. Assessment of the key strengths and weaknesses of each study was made independently by three authors contemporaneously with data extraction, and harmonised in the same fashion as the other data extraction.
Data synthesis was conducted by grouping studies according to theoretical concern and primary methodology. Recommendations for practice were harmonised and then presented, with the degree of support indicated by the number of studies in which they were recommended.
Results
Twenty-six studies were included in this scoping review (Fig. 1); Table 1 presents the primary data extraction. Of the 26 studies, 21 were from the UK, 2 from Germany and 1 study was completed in each of Republic of Ireland, Australia and South Africa. The majority were set within general acute psychiatry settings, with a few in a range of other settings (low secure, psychiatric intensive care units, old age, eating disorder, rehabilitation, medical and surgical wards and perinatal units).
Fig. 1 PRISMA 2020 flow diagram for new systematic reviews that included searches of databases, registers and other sources.
Of those studies using a method that recruited participants, the range of patient participants across 16 studies included was 5–301, with a median of 26 and a mode of 6, 8 or 10. The range of staff participants in the 13 studies included numbered 9–290, with a median of 31 and a mode of 21. The difference in participant numbers reflects more low-number, in-depth interview studies being carried out with patients and more survey studies of staff.
Not all studies offered a definition of an in-patient psychiatric ward round. Features of a definition included in more than one study were the following: being scheduled; being conducted away from the bedside; being consultant led; involving a MDT; having patient involvement; involving patient assessment; creating or reviewing a treatment plan and risk assessment; and being an opportunity for teaching.
The majority of studies did not use a specific theory. However, among those that used a specified theory, two used lean methodology, two used critical realism with one each using systems research, the phenomenological–hermeneutical method and constructionism.Reference Curtis, Sethi and Ahmed10–Reference Noble and Billett16 We did not find any studies informed from a specific psychological therapeutic perspective. One study, Rapsey et al, used a trauma-focused approach.Reference Rapsey, Watson and Dafforn17 While trauma-focused therapy has been defined as ‘any therapy … in which the trauma focus is the central component’ rather than as a traditional school of psychology, it still offers a different theoretical perspective.Reference Schnurr18 Despite this difference in focus, Rapsey et al obtained the same themes as those found by the other qualitative studies using interviews or focus groups.Reference Rapsey, Watson and Dafforn17 In those studies focused explicitly on power, and in some focused on experience in which power, control and hierarchy featured prominently, the influence of critical theories was evident although not explicitly elaborated upon in the manuscripts.Reference Cappleman, Bamford, Dixon and Thomas6,Reference O’Reilly, Kiyimba and Drewett13,Reference Swartz19–Reference Ryan22
The experience of ward rounds was the focus of nine studies,Reference Labib and Brownell7,Reference Rapsey, Watson and Dafforn17,Reference Kidd, Singh, Lord, Kadir, Bell-Jones and Collins20,Reference Carey, Lally and Abba-Aji21,Reference Yim, Jones, Cooper, Roberts and Viljoen23–Reference Chapman, Ingram, Collyer and Brifcani27 the structure of ward rounds was the focus of five and Reference Fiddler, Borglin, Galloway, Jackson, McGowan and Lovell15,Reference Roche, Powell and Chapman28–Reference Fewtrell and Toms31 efficiency was the focus of three.Reference Curtis, Sethi and Ahmed10,Reference Lennard11,Reference Mattinson and Cheeseman32 Power was the explicit focus of three papers,Reference Cappleman, Bamford, Dixon and Thomas6,Reference O’Reilly, Kiyimba and Drewett13,Reference Swartz19 shared decision-making the focus of twoReference John12,Reference Holzhüter, Schuster, Heres and Hamann33 and a unique focus was found in four.Reference Coffey, Hannigan, Barlow, Cartwright, Cohen and Faulkner14,Reference Noble and Billett16,Reference Milner, Jankovic, Hoosen and Marrie34,Reference Vietz, März, Lottspeich, Wölfel, Fischer and Schmidmaier35
The most common methods used were cross-sectional surveys in 11, interviews in 11, audit or plan-do-study-act cycles in 3, time use survey in 2, ethnographic methods in 2, focus groups in 2 and personal reflection in 1. Several studies combined surveys and interviews. We identified no experimental studies or non-ethnographic longitudinal studies.
A small number of studies described innovations involving substantial changes to traditional ward round structure. Hodgson et al, on the other hand, found no viable alternative to the traditional ward round.Reference Hodgson, Jamal and Gayathri30 Two studies examined group models of ward rounds;Reference Fewtrell and Toms31,Reference Davis and Dorman36 these concluded that such a change shifted the focus away from illness towards patients’ practical and social concerns. Fiddler and colleagues described the change process of moving from a weekly to a daily ward round model.Reference Fiddler, Borglin, Galloway, Jackson, McGowan and Lovell15 That paper focused on the process of change rather than the effect of the changes themselves, concluding that it is possible to make changes to such an established practice as in-patient ward rounds.
O’Reilly and colleagues did not specify any recommendations for ward rounds, but posited that future research on these should consider mixed quantitative methods.Reference O’Reilly, Kiyimba and Drewett13 They found a discrepancy between their observations of decision-making in ward rounds and patients’ reported satisfaction with these decisions outside of them. Wagstaff and Solts drew similar conclusions, although it was not the focus of their research.Reference Wagstaff and Solts25 They observed that patients often reported not being able to recall being introduced to the professionals present at the ward round, when in fact they had been.Reference Coffey, Hannigan, Barlow, Cartwright, Cohen and Faulkner14
From the findings of the studies, several recommendations were given. Many of the studies made recommendations for the conduct of ward rounds (Table 2). Recommendations made by more than one study included fewer people in ward rounds; increasing patient involvement; dedicated preparation time; providing feedback or access to ward round records; having structured ward round documentation; regular appointment times; focusing on preparing patients for discharge; and providing information about ward rounds. Each of the following were recommended by one study each: family involvement; peer advocacy; the availability of refreshments; the use of hybrid ward rounds (in both person- and technology-assisted ward rounds); considering the use of a group format for ward rounds; having the names of professionals involved in ward rounds listed on the door; having familiar staff present; ad hoc daily ward rounds rather than weekly and structured; addressing patients directly when using interpreters; pharmacist involvement in ward rounds; and, lastly, staff given instruction about how to do ward rounds, in addition to more teaching taking place during ward rounds.
Table 1 Summary of papers included in the scoping review
MDT, multidisciplinary team; SHO, senior house officer; CPN, community psychiatric nurse; SDM, shared decision-making.
Table 2 Recommendations made by papers in the scoping review
Discussion
We have conducted, to the best of our knowledge, the first review of research literature focused on psychiatric ward rounds, and collated the recommendations for practice made in that research. Throughout the literature a key tension is apparent, although rarely directly addressed, between having too many people in the room and MDT working. Much of this seems to stem from the fact that ward rounds are routinely used as an opportunity to assess the patients’ mental state, which feels very exposed in a room full of often unfamiliar faces.Reference Cappleman, Bamford, Dixon and Thomas6,Reference Coffey, Hannigan, Barlow, Cartwright, Cohen and Faulkner14,Reference Yim, Jones, Cooper, Roberts and Viljoen23 However, this conflicts with patients’ wishes for greater involvement in their care, which relies upon all relevant decision-makers being present when decisions are made. In models of care in which the primary decision-making forum is MDT meetings with no patients present, these are largely excluded from those decisions. Moreover, non-medical professional groups can define their role in in-patient psychiatric care as encompassing advocacy for patients in medically orientated systems, which would be lost without the MDT.Reference Stacey, Felton, Morgan, Stickley, Willis and Diamond37 This results in trade-offs between overcrowding, collaboration and efficiency.
Of the few studies to have examined major changes to ward round structure in resolving such tensions, no studies were designed to show therapeutic or service level benefit. Both of the group round studies are over 35 years old, and it is unclear whether these models could be adapted to meet current institutional, privacy and other regulatory concerns.Reference Fewtrell and Toms31,Reference Davis and Dorman36 Fiddler et al’s change to daily ward rounds with more frequent, shorter and flexibly timed patient reviews goes against the recommendations made in most, but not all, other papers recommending regular appointment times.Reference Coffey, Hannigan, Barlow, Cartwright, Cohen and Faulkner14,Reference Fiddler, Borglin, Galloway, Jackson, McGowan and Lovell15 Moreover, Fiddler et al’s study was not designed to compare patient or staff satisfaction, but focused on the change process itself. The daily meeting approach in this study, although not explicitly cited, may draw from approaches used in therapeutic communities that typically have daily community meetings.Reference Campling9 One might consider alternative approaches to ward rounds within the wider existing model of in-patient working: for example, having weekly brief and focused practical MDT ward rounds by appointment with each patient, family and external professionals alongside individual informal medical reviews. This could reduce the level of exposure felt by patients in a room crowded with professionals, and would remove the concern that an unsuccessful ward round means another week wasted.Reference Foster, Falkowski and Rollings26 Another approach could be that of Hansen and Slevin who, based on therapeutic community principles of reality confrontation and communalism, introduced twice daily community meetings alongside weekly ward rounds.Reference Hansen and Slevin38 Such suggestions are speculative and likely to have significant implications for staff time, unless strict boundaries around meeting times and the independent purpose of different meetings are maintained.
The recommendations identified aimed at improving ward rounds, in their current most common format, hold good face validity in the view of the authors. However, there are no experimental studies implementing these recommendations. As demonstrated by Hansen and Slevin’s implementation of therapeutic community principles, cluster-randomised trials of such changes are feasible.Reference Hansen and Slevin38 The three studies using audits, or plan-do-study-act cycles, did show that it is possible to improve the consistency of ward round content and documentation.Reference Curtis, Sethi and Ahmed10,Reference Turel, Perera, Lewin and Al Uzri29,Reference Mattinson and Cheeseman32 Only one assessed the impact on length of stay, and did not find a difference.Reference Mattinson and Cheeseman32 Overall, the studies identified either were not designed to implement their recommendations or had limited or no ability to assess changes in key outcomes such as patient and staff satisfaction, quality of intra-round communication, objective measurement of patient involvement or length of hospital stay. Thus, the empirical support for the recommendations from this review is weak. It is our view that the recommendations collated in this review are unlikely to cause harm. In collecting the current available evidence on psychiatric ward rounds, and in the absence of more robust evidence, our findings could be considered for use as a starting point for quality improvement projects.
The strength of the evidence is particularly important to consider when several of the most common recommendations have significant implications for clinical resources, principally staff time. This includes pre-ward round meetings, post-ward round debriefings, pharmacist involvement and greater family involvement. Staff time as a resource is a major limiting factor on, the ability to implement the recommendations in this review. In the UK, as in other countries, staffing vacancies and increasing administrative responsibilities being placed on front-line nursing, medical and allied health professionals create considerable pressure.Reference Gilburt and Mallorie39 Improving patient experiences of ward rounds is likely to involve some additional input of these limited resources.
Our review has highlighted the need for future research on ward rounds in vivo, to triangulate a combination of patient and staff reports with direct observation. Many of the included qualitative studies relied solely on patient reports with close alignment to constructivist approaches. This has led to neglect of consideration of external events and specific aspects of the clinical context. Quotes used in this body of research, such as patients describing feeling anxious because of ‘not hearing what I want to hear’, were almost entirely devoid of clinical context.Reference Kidd, Singh, Lord, Kadir, Bell-Jones and Collins20 There may or may not be extremely sound reasons, such as risk of suicide, why patients do not hear what they want to hear in ward rounds. Alternatively, the person may have a disorder that affects their interpersonal functioning and would be expected to influence their interpretation of ward round interactions. Perplexingly, the interview studies we identified gave minimal, if any, consideration to how the fact that their participants were suffering a mental disorder sufficiently severe to warrant hospital admission might influence the data obtained in interviews. In the three studies that did triangulate between interviews and observations, important discrepancies were found between patients’ perceptions and events as they occurred.Reference O’Reilly, Kiyimba and Drewett13,Reference Yim, Jones, Cooper, Roberts and Viljoen23,Reference Wagstaff and Solts25 The lack of triangulation with either direct observation or clinical information is a major limitation of the qualitative studies included in this review. Moreover, differences between patients’ memories of their ward rounds and what happened in those ward rounds are informative as a potential subject of future inquiry in itself. For example, one might wish to understand why patients may still report feeling uninvolved in decision-making despite being the main talkers in rounds, or why they are unable to recall being introduced to those present.Reference Yim, Jones, Cooper, Roberts and Viljoen23,Reference Wagstaff and Solts25
Within the psychodynamic approach to research on therapeutic communities, attention is specifically drawn to such seeming contradictions.Reference Campling9,Reference Biel and Plakun40 Contrastingly, we found an almost total absence of examination of interactions within ward rounds from any distinct psychological school. Because many of the study authors were psychologists or psychiatrists by profession, this was somewhat surprising. It seems to us that a variety of psychological lenses, from traditional psychodynamic to compassion-focused therapy, may hold valuable insights into understanding and improving communication within, and experience of, ward rounds for patients, families and professionals.
Similarly, there were no studies focused on the physical environment or sense of space. In fact, with a couple of exceptions, the only acknowledgement of physical space was alluded to via the sense of overcrowding or brief mentions of moving chairs.Reference Rapsey, Watson and Dafforn17,Reference Swartz19,Reference Hodgson, Jamal and Gayathri30 Perhaps this is because the ward round room is seen as either mundane compared with the revolutionary spaces such as the Paddington day hospital, or because studies of in-patient space have either focused on the in-patient setting broadly or on other particulars.Reference Spandler41 Similarly, with the primary exception of Swartz, little attention was paid to the ritualistic nature of ward rounds.Reference Parissopoulos, Timmins and Daly5,Reference Swartz19 Roche et al did, however, recommend the provision of refreshments.Reference Roche, Powell and Chapman28 Nevertheless, this was not put into the context of the near universal symbolism of hospitality indicated by such provision, or how this might be consciously employed to put all attendees on a more equal footing. Equally there was no discussion regarding how such provision might interact with broader clinical agendas regarding risk reduction if hot drinks are provided, or improving cardiovascular health if snacks are provided. Sharing refreshments between professionals and patients in ward rounds is one example of how the clinical ritual could potentially be changed, but such matters are not explored in the published journal literature.
As well as the limitations of the literature itself, our review has its own weaknesses. It was limited to those academic papers explicitly referencing psychiatric in-patient ward rounds in a searchable manner. There is undoubtedly a great deal of relevant material in other academic sources, books and the grey literature that provides accounts of in-patient admissions more broadly; these would not have been retrieved by our search terms. However, reviewing all literature on in-patient care for references to ward rounds would have been a prohibitively large task. Similarly, there is likely to be a large number of hospital audits and quality improvement projects not available to us. Most of the retrieved literature is from the UK, and we conducted our review in the English language only. It is unknown how much primary literature in other languages has not been included, or how the findings and recommendations from this review would translate to models of care in other countries.
In conclusion, we have conducted the first scoping review assessing the state of the published academic literature focusing on in-patient psychiatric ward rounds. We found that the majority of the published literature focused on psychiatric ward rounds used cross-sectional surveys or interviews. The experience of participating in ward rounds and matters of efficiency were the most common topics of research. Most of the identified literature did not have a clear theoretical underpinning. Future research on psychiatric in-patient ward rounds should consider triangulation in data collection, and focus on assessing the effectiveness of implementing changes. We have collated recommendations, with the frequency of those recommendations across papers providing some indication of the level of expert support for those recommendations.
About the authors
Benjamin Williams, BM, BS, MSc, PhD, MRCPsych, Consultant Psychiatrist, North View, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK. Siobhan Richardson, BSc, Trainee Advanced Nurse Practitioner, North View, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK. Georgia Jameson, BSc, Equality Diversity and Inclusion Partner, Equality, Diversity and Inclusion Team, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK. Oluwatomilola Olagunju, MBBS, MClinEd, FHEA, MAcadMEd, Psychiatry Core Trainee 2, Mersey and West Lancashire Teaching Hospitals NHS Trust, Prescot, UK.
Supplementary material
Supplementary material is available online at https://doi.org/10.1192/bjb.2025.10139.
Data availability
Data availability is not applicable to this article because no new data were created or analysed in this study.
Author contributions
B.W. was responsible for conception and design, analysis and interpretation of data and drafting. S.R. was responsible for data acquisition, analysis and interpretation and critical review of drafts. G.J. contributed to the conception and design of the work, reviewing the draft and providing patient perspective on the work at all stages of development. O.O. contributed to the acquisition, analysis and interpretation of data and drafting the manuscript. All authors approve the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Funding
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of interest
None.
Transparency declaration
The manuscript is an honest, accurate and transparent account of the study being reported; no important aspects of the study have been omitted, and any discrepancies from the study as registered have been explained.
Open access
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