Understanding Different Functions of Ward Rounds In Paediatric Oncology: A Qualitative Study

Purpose The ward round (WR) is a core routine for interprofessional communication and medical care planning. It allows health care professionals (HCP) and patients to meet regularly and encourages patients to take an active role. Despite its high value for patient-centred care, there is no universal denition of WR. Little is known about the attitudes of participants towards a ‘good’ WR. This study aims to capture the experiences and expectations of participants to better understand WR needs. Methods 13 Semi-structured interviews were conducted with patients, parents, nurses and doctors of a paediatric oncology ward. The phenomenological framework by Colaizzi was used to identify major themes.


Introduction
The ward round (WR) is an essential part of daily hospital practice where the multidisciplinary team exchanges information and discusses further care planning [1]. Contemporarily, WR do not only take place in a conference room, but also at the patient's bedside, giving patients the opportunity to ask questions and take an active role [2]. Recent research shows that besides timing and location, teamwork and communication are also of great importance for a successful WR [3].
In paediatric oncology, parents participate in the WR, which can increase the satisfaction of both the professional team and families [4] and shorten hospital stay [5]. While family-centred rounds have become standard practice on paediatric wards, they also require special communication skills [6].
Additionally, the seriousness of a cancer disease and the long-lasting therapy process place signi cant emotional stress on families, which always has to be considered during WR [7,8].
Despite being a core routine in every hospital ward, there is no agreed de nition of a WR [9]. In the busy day-to-day work of nurses and doctors, the WR becomes an increasingly neglected element of their routine [10]. It also rarely appears in textbooks and is not systematically taught at university [11]. Young healthcare workers learn to conduct a WR 'on the job', without any scienti cally proven recommendations or standardised feedback procedures [12]. There is a fair amount of research on certain WR aspects, like time or location, but information about participants' attitudes and personal experiences with WR are still lacking.

Purpose
To understand what WR means to different stakeholders of a paediatric oncology round, we conducted semi-structured interviews with doctors, nurses, patients, and parents. We intended to capture experiences and perceptions made by different participants and understand their expectations and requirements towards the WR.
Thus, we aimed to create a basis for multidisciplinary accepted and scienti cally supported recommendations.

Methods
For this study, face-to-face semi-structured interviews were conducted from January 2018 until August 2019. Interviews were transcribed and analysed using a qualitative descriptive method (Colaizzi [16]; Fig.  1), in order to gain a deeper understanding of the lived experience of individuals [13]. Participants were not restricted in their input to ensure that important aspects were not missed [14].
Ethics committee approval was obtained from Hannover Medical School prior to recruitment (No. 7700, 05.03.2018). Inclusion criteria were: su cient speech comprehension; participation in > 10 WR as a nurse/doctor/parent/patient; age 11-18 (patients); inclusion of further interviewees until theoretical saturation [15]; written consent for participation. An overview of respondents is provided in Table 1.  Table 3 shows an example of the analysis process. Table 3: Example of the analysing progress from interview D (Father). Answer to the question: "Could you explain a bit more detailed, why you restrained yourself during ward round?" Analysis was done by two authors (LB, LG) and validated by team discussions until reaching consensus and con rmability.

Results
A total of 13 respondents were recruited: 3 doctors; 3 nurses; 3 parents; and 4 patients. Interviews had a total duration of 5 hours and 3 minutes with an average duration of 22 minutes 46 seconds per interview.
Patients were between 11 and 18 years old, health care professionals (HCP) had between 1 and 31 years of work experience.
Four major themes with a total of 30 corresponding categories emerged (   All major themes (MT) and their categories are displayed in Table 2.

Aims and Functions of a Ward Round
Interviewees from all four groups (11 out of 13, Table 2) named "The exchange of information" as one important function of WR, including the discussion within the professional team and between HCP and families. They stated, by this all participants were brought to the same level of knowledge. Exchanging knowledge initiated thinking processes and created the basis for cooperative problem solving. It also served to control current health status, revise therapy plans, and reveal potential errors before they happen (critical incidents). Information exchange during WR had different meanings to different groups. One doctor said: "The ward round team has to manage the balancing act between: We have to get the ward round done quickly and somehow just communicate medical knowledge, while always keeping in mind what the things we say actually mean to the families" (Interview F). Parents mentioned they found it di cult to ask questions, because they feared the meaning of the delivered information.
The category "Emotional support" was mentioned in 12 of 13 interviews, thus most frequently within this MT. Parents explained, WR helped them to cope. Knowing their children were looked after comforted them. One parent said: "Because you have to face this situation. You can't just talk it away and say: it will be ne and resolve itself […] and the ward round can support you doing that by saying: This is reality now and we do our best so that everything will be ne again" (Interview D). Patients underlined that the WR made them feel valued and looked after as someone came to talk to them. This is illustrated by a quote from a patient's interview: "It's just nice that you are still seen by the doctors, just so they can ask you: How are you? Are you okay?" (Interview I). HCP felt more secure with regard to solving problems by sharing responsibility with their colleagues.
Nurses (3/3) and Patients (2/4) brought up the WR role in building relationship and trust. Creating a bond between HCP and patients made the therapy process more personal. Patients emphasized the importance of getting to know the doctor's character. It helped them understand the doctor's decisionmaking process. A patient explained: "As a patient, you don't have too many points of contact with the doctors. But you nevertheless still allow them to take control over your therapy and everything else. So, you put a lot of trust in them without knowing who the person is. Who is the person that makes those decisions for me that I can't make myself?" (Interview K).

Structure and organisational requirements
Two categories named by all of the four interview groups were: "Preparation of WR" and "Clear Structure of WR".
All interviewees wanted their co-participants to be well prepared before WR. Also, HCP expected their colleagues to have all documents and records available. Important information should be easily accessible and prepared beforehand.
12 out of 13 interviewees criticized that WR proceeded unstructured, therefore "you sometimes don't notice certain things, you just jump to the obviously pathological results […] and then sometimes you overlook things", as a doctor explained (Interview E). Not having a de ned structure was also recognised as time-consuming. Some interviewees suggested that a standardised guideline could help by de ning the order of topics and prioritising them.
Interviewees named a "respectful working atmosphere" as one requirement for a 'good' WR. They wanted WR participants to be appreciative, listen to each other, and accept people's opinions. Every member of the WR team, including families, should feel they are allowed to tell their opinion openly and honestly. Families emphasised they always sensed if the healthcare staff worked as a team or not. A team working together made patients and parents feel more secure.
'Time' was a controversial topic in the interviews. While parents and patients felt that WR was too short, doctors always talked about time pressure. They expressed the wish that WR should be effective and less time consuming. Interviewees from the professional team nevertheless said that it was important planning enough time to be able to answer all questions and go into detail if necessary. For HCPs, it was most important to ensure having enough time to thoroughly consider choices and make well-thought-out decisions, as opposed to hasty ones, or even needing to postpone a relevant decision due to time pressure.

Ward round participants and interpersonal communication
Interviewees described both advantages and challenges of interprofessional teamwork in the WR. "Communication at eye-level" appeared in all interviews except for those with doctors: Parents and patients said they would have liked more layperson language, and that the healthcare team should better adjust communication to their emotional situation. One patient put special emphasis on non-verbal communication and sending signals. She described a situation experienced during WR: "To me, it looked like they were not sure what the results of the sample would be, or rather actually I already gured out that, when it takes so long to get the results, there's a reason for that […]. The ward round team didn't convey any particular uncertainty, I would say, they just said: 'we have to examine that further'. But when you think about it […], you will quite easily come to the conclusion that something must be abnormal" (Interview K). As the patient's illness was serious, they interpreted the missing information as a negative sign. Excluding or trivialising information sends signals to the patient, even if the doctor doesn't intend to, which can plunge the patient into a negative spiral of worst-case-scenarios. Patients also emphasised that doctors communicated through actions and facial expressions, such as looking at the clock frequently or moving around nervously. Families got the impression that doctors had time pressure and did not dare to ask questions anymore. One patient said: "The doctors have to go through all the other rooms as well, […] I don't want to delay someone like that, because I know, they need to go on" (Interview I).
Interviewees from all four groups would have liked the psychosocial team to attend the WR to support decision-making and take care of questions concerning psychosocial topics. Most interviewees preferred a smaller group of people. A resident said, large WR teams made the ward round become a "show event", which she thought was "absurd" (Interview F). A patient said: "When the senior doctor conducts the ward round, it feels as if basically everyone attends. I think there's a difference between three people standing around your bed or ve. You then feel like being under siege, when everyone is standing around looking at you." (Interview I). Other interviewees said, large groups created a less intimate atmosphere and could not assure that everyone got the required personal attention. Interviewees from all four groups described how their opinions and skills changed over time, and how that changed the WR. Professionals said they gained experience, which boosted their self-con dence so that they participated more actively in WR and expressed their opinion more openly. Parents underlined that initially they did not dare to criticise medical staff during WR. They only received information, but never communicated their own opinion. Gaining more knowledge on the illness, they became more critical and questioned decisions. Additionally, parents asked for a guideline to make the WR more transparent in the beginning of the treatment. A mother said: "I would like to have an information lea et for families about the ward round before the rst stay in hospital. That information could explain: what is the ward round, what parts does it consist of? And what should it clarify?" (Interview C). At rst, parents often didn't understand the purpose of WR and if they were allowed to ask questions.
When patients started their treatment, the WR scared them as something special and alarming. One patient explained: "In the beginning, you are rather intimidated when so many experts come into the bedroom" (Interview K). Another patient added: "In the beginning it's always like, […] really terrifying anxieties: 'Oh my god, the doctors are coming, something really important must be going on'. And then over time you simply learn: okay, they just want to look how you are and tell you the next steps and not tell you the next dreadful news" (Interview I). After attending a few rounds, they realised that WR were normal daily routine.

Discussion
To the best of our knowledge this is the rst study analysing the function of WR in paediatric oncology that considers all relevant stakeholders. Altogether we identi ed four MT, comprising a total of 30 categories. Respondents collectively stated that requirements for a successful WR were not yet standard practice and should be implemented in daily routine.
An essential nding was that 12 out of 13 interviewees de ned "emotional support" as one of the main WR functions. It even appeared more often than "handing over information" (mentioned in 11 interviews).
Research shows that parents are encouraged by seeing so many different people care for their children [17], and that including families in the discussion process during WR improves the satisfaction of parents and patients [4,18,19]. Additionally, collecting information comforts parents of children with cancer [20]. It is a coping mechanism helping people in stressful situations by reducing uncertainty and regaining a sense of control [21,22]. A recent study exploring parents' perceptions of ward rounds highlighted that parents highly value it primarily for the opportunity to collaborate with the clinical team and to ask questions [42].
In this study, only patients and nurses described the WR as an opportunity to build and strengthen relationships, while neither parents nor doctors mentioned this. Patients explained that knowing their doctors helped them understand decisions. Decision-making is a complex process and is in uenced by personal attitudes, values and beliefs [23]. Understanding how decisions are made helps patients to accept and support the decision and improves their cooperation [24]. Another study showed that a good Despite previous research suggesting open and honest communication with families, our study highlights that this is still lacking in practice [31,32]. We see a need for more open communication, where everything is said explicitly so patients do not have to focus on non-verbal communication.
Our data shows that interviewees would prefer a member of the psychosocial team to attend the WR. In literature, the optimal team composition in WR is not yet de ned and often varies [33]. Literature shows that multidisciplinary WR achieve greater patient involvement, improved teamwork and better consideration of patient's needs than multidisciplinary team meetings [34]. In paediatric oncology, looking after families' psychosocial concerns can prevent noncompliance [35]. Involving members of the psychosocial team in WR could therefore improve cancer treatment. However, when implementing multidisciplinary rounds, team size has to be considered as our data shows that most patients and parents would prefer smaller WR teams.
Finally, our results indicate that neither professional team members nor families felt well prepared for WR. International research has already revealed that this is not only a problem in Germany, but can be found globally. While communication skills become more important in university education programmes, the WR is not yet part of the curriculum [11]. Recently, research has explored new WR training programmes for healthcare staff [36,37]. It is striking that many of these are designed for medical students only, despite scienti c agreement on teamwork and communication being signi cant elements of WR [5].
Research shows that interprofessional learning can improve both [38].
Patients of this study unveiled that emotional preparation for WR was challenging. Originally, they were scared of WR, until they understood that it is a daily routine and nothing bad happens necessarily. This goes hand-in-hand with Berkwitt and Grossman's ndings [39], who observed that paediatric patients associate WR with negative feelings when starting treatment. It can therefore be assumed that healthcare staff could spare patients anxieties and insecurity by explaining the purpose of WR early-on, which is consistent with other studies [44].
Little is known about the relevance of different competences in speci c disciplines. An interesting study compared relevant competences in surgery and psychiatry by interviewing ward staff and found, not surprisingly, that clinical skills were mentioned more often in surgical interviews, while nonverbal communication was described more often in psychiatric interviews [45]. However, the patients' or the relatives' perspectives were not considered. To ensure the best possible doctor-patient communication all relevant perspectives have to be included, as our study demonstrates and explores.
Our study has several strengths and limitations. The interviews provided a realistic understanding of the participant's experiences and covered a wide range of aspects. However, a limitation inherent to qualitative research is that results cannot easily be generalised. Nevertheless, our data can serve as a base for further research with more respondents to reach greater generalisability.
Our data represents experiences from a single institution. Experiences of members of WR on other oncology wards may differ. However, our study focused on a multidisciplinary team, patients with severe illnesses and their families, emotional and stressful situations, and relationships between different WR members. These aspects can be found in other oncology wards accordingly. We therefore assume that our results have some sort of external validity.
As we could only include interviewees who were able to speak and understand German, our results cannot be generalised to foreign-language speakers and participants with a migratory background as their experience might be different. Language barriers are still a huge problem in healthcare [40]. Social, cultural and religious differences are additional obstacles in the treatment of paediatric patients [41]. As the WR is the central place of communication, these aspects should be examined in future research.
Lastly, we included only a limited number of interviewees. Nevertheless, within this small cohort, maximum diversity was attempted to achieve representation of all major groups participating in WR, work-experience from 1 to 31 years, different genders and age variation. We stopped the recruitment of participants when we reached a theoretical saturation [15].
The amount of literature regarding WR in paediatric oncology is limited, and, to our knowledge, does not cover comparing experiences of all stakeholders. Thus, this study adds substantially to the small but growing body of literature regarding WR in general and in paediatric oncology in particular.

Conclusion
Our research shows that for stakeholders in in-patient paediatric cancer care, WRs have several important functions, aims and potentials. In accordance with recent research attempting to de ne a 'good' WR, our results highlight the need for improvement. Especially in terms of relationship building, emotional support and communication, the potential of WR is not yet fully explored. Additionally, WR require guidelines to prevent errors and help the team structure discussions. Lastly, families and carers should be prepared before their rst WR. The data from this study can be used to develop a successful WR training for nurses and doctors. It also gives an understanding of what a 'good' WR needs in order to meet the expectations of all stakeholders and to improve the quality of cancer care. Figure 1 Seven steps of Colaizzi's theoretical framework [16]