Chapter 12. On the ward
Time and ‘take’ management 383
Verbal communication 385
Written communication 389
Before, during and after theatre 392
TIME AND ‘TAKE’ MANAGEMENT
General time management
Organizing yourself
• use a notebook, at least A5 in size and preferably including a ‘page-a-day’ diary
• at the front, make a list of all the patients in your care that you can keep adding to or deleting as the days pass: include patient identifier numbers, dates of birth, working diagnosis and allergies
• for each day, write down the list of jobs you are given for each patient; indicate alongside those which have been completed and those for which you have seen results
• carry a list of blood and other request forms, referral forms and discharge prescriptions in the back of the book.
A daily routine
At the start of the day
• identify and familiarize yourself with any overnight admissions
• check if any of the patients on the ward were unwell overnight and were seen by the overnight team; review them yourself before the ward round
• review results from the tests you ordered yesterday or the day before.
During the day
• try to get things done as soon as they are requested, e.g. fill out blood forms on the ward round
• fill out requests for tests that involve other departments, e.g. radiology, as early as possible, since other people need to organize their work too
• predict discharges: even if some drugs might change on the ward round it is worth having the rest of the discharge form prepared
• make sure that you are not doing tasks that should be done by others; learn to say ‘no’ if you are given inappropriate tasks
• take your breaks: you will be much more efficient
• leave jobs that do not require much energy until the end of the day
• if you are struggling, ask for help and, if you have time to spare, offer it.
At the end of the day
• check your list for any requests not actioned or results not back: make a note in your diary reminding you to do, or check, these tomorrow or on the appropriate day
• check that all routine tasks for the evening and night-shift have been completed before you leave, e.g. fluid, warfarin or insulin prescriptions
• prepare any outstanding blood forms that need to be ready first thing for phlebotomy the next day
• if you know you will not get something done before you finish, say so and pass it on to the overnight team
• review any ill patients and decide if they will need further review overnight
• make time for an effective handover (see ‘Verbal communication’, p. 385).
The ‘take’/‘on-call’
If you are organized in your regular work, your performance during ‘take’ or ‘on-call’ duties will reflect this. On a receiving shift you can expect that:
• the volume of work may be greater
• the patients may be sicker, mandating more urgent action
• the work will be more unpredictable
• you will be part of a team, required to respond to the triage assessment made by others and acting timeously to requests from all members
• you will have more staff to help you and you should delegate where appropriate
• the work will rarely stop and you will need to make more effort to plan breaks that ‘fit in’, including taking food with you to avoid going hungry in case there is no time to visit the shop; work with the others in the team to plan when you will each take time out.
Working at night
The majority of hospitals now employ ‘hospital at night’ teams to provide out of hours care. These teams are comprised of a number of doctors from different hospital specialties, who between them have the full range of skills and competences required to deliver safe clinical care overnight. Most teams also incorporate senior nursing staff who have been trained to assess patients and perform basic procedures, including cannulation. Such senior nurses will often be the first port of call for ward-based nursing staff if they need a cannula inserted or a patient reviewed. If required, a medical member of the team will then be called.
The ‘hospital at night’ team also softens traditional boundaries between specialties and, irrespective of their ‘base’, the whole team is expected to work together. Doctors working in specialties that are traditionally quiet overnight will be expected to assist their colleagues working in busier areas, e.g. medical units, A&E. Senior trainees from one specialty may also be called to assist junior trainees in another with procedures.
The hospital at night system works best if there is a formal handover from day to night staff. This allows sick patients on the wards and other potential problems to be highlighted (see ‘Handover’, below). Remember the ‘golden rules’ of working out of hours:
• when you see patients, WRITE IN THE NOTES
• if you do not know what to do or are concerned, CALL SOMEONE.
VERBAL COMMUNICATION
Good communication is essential between colleagues and with patients and their families.
Communicating with colleagues
Handover
In hospital practice, good handover between day and night shift teams is crucial. It provides the only opportunity to inform night staff about sick patients and may well be their only link to events occurring during the day. Handovers aim to convey important information from one party to another in a way that can be easily understood and actioned. This includes information about:
• unwell patients or others who need review or discharge
• patients who have the potential to become unwell
• pending investigations that need to be reviewed
• other jobs that need to be completed.
Before the handover meeting, it helps to prepare a list of the information you want to communicate and to distinguish urgent cases or tasks from routine ones. In many hospitals the formal evening handover is a regimented affair involving several hospital departments. Pay attention and make notes: you might be asked to see the patients discussed later.
Telephone
Telephone communication has to be conducted without the benefit of non-verbal cues. This makes it difficult to know how well your message is being understood at the other end. To make the most of such communication:
• be clear: speak audibly and slowly
• be structured: see ISBAR below
• be organized: have relevant information to hand, e.g. recent investigation results; if making a referral or phoning a senior colleague, you may also wish to jot down the key points you want to make under the ISBAR headings; see below.
ISBAR
The person at the other end of the phone needs to hear information in a form they can follow, allowing them to build a picture they can visualize. This is particularly true if they have just woken up: give them a minute to waken up properly to avoid having to repeat the story. One way of structuring these calls uses a technique based around the mnemonic ISBAR:
• Identify: identify yourself, the person you are speaking to and the patient
• Situation: summarize the key problem and why you are calling; if it’s urgent, say so!
• Background: give a structured synopsis of the story; only provide the relevant information
• Assessment: say what you think is going on; stating the obvious is helpful
• Request: outline what you want them to do.
Communication with patients and families
You will need to talk to patients and families on a regular basis about investigations, diagnosis and treatment. Good communication involves patients and/or carers in a two-way discussion, rather than being simply a process of imparting information. It is often as much about listening to what is said and observing non-verbal cues as it is about talking.
Whom to communicate with
You have a duty of confidentiality to adult patients. Before you communicate with any family member or representative about them, you need to seek their consent. Families do not always understand this and may expect you to pass information over the phone when they call the ward, to answer questions when you meet them in the corridor or to be advised of results before the patient. They may also express a wish for you not to tell the patient something or insist on coming with a patient into a clinic consultation room.
However, the patient may not like or trust a particular family member, or they may wish to tell the family selected information in their own way and at their own pace. Any adult who is mentally capable, even if they are elderly or dependent on others, has the right to choose with whom they will share the information and when they will do it.
In the case of inpatients, it can help to clarify the lines of communication at the outset. Identify their main contact or next of kin. Clarify whether any information should be held back from the contact pending discussion with the patient. When dealing with outpatients, check with the patient before they come into the consultation room if they wish their relatives to accompany them.
How to communicate
Communicating well comes with practice; the following principles are a guide:
Environment
• try to create a comfortable environment which is quiet
• ensure privacy and prevent interruptions, e.g. give your bleep to somebody else
• avoid having a desk between you and the patient/family; it will act as a barrier
• sit at the same eye level as the patient: do not stand over them.
Background and agenda
• explain who you are
• if you are talking to a relative of the patient, verify who they are and what relationship they have with the patient
• clearly introduce what the meeting is for and what you hope to cover in it, e.g. ‘I have the results of your test: I’d like to go through the results and then talk about some of the treatment options’
• find out what they know already: ‘can you tell me what you have been told so far’
• establish if there is anything else they want you to address.
Main conversation
• try to keep to the structure you outlined at the start
• if you have a lot to say, try to break it up into manageable sections to avoid overwhelming the patient/family
• be aware of your body language: adopt an open position, i.e. avoiding crossed arms/legs
• regularly check whether they have any questions
• answer any questions honestly.
Closure
• ask if they have any remaining questions or concerns
• summarize what you think are the main points from the discussion.
Breaking bad news
This task is best performed in a controlled environment by experienced clinicians. However, all doctors may be required to do so in an emergency situation. If you are not prepared, it will be stressful for you and for the patient/family.
Preparation
Know the case and the proposed medical plan. Consider what questions the patient/family are likely to ask. Ideally, inform the patient that their results should be available on a certain day, at a certain time and check if they would like to be told them, and also if they would like any family members to be with them at the time.
Know what you want to say ahead of time, but be prepared to adjust this depending on the response to the initial outline of information you give.
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