Clinical methods

Nursing rounds

A procedure in nursing education and in later practice in which one or more visits to a h
ospital patient are scheduled by twoor more nurses to coordinate care, troubleshoot, respond t
o patient needs, and share insights.

Four types of nursing rounds:

1- Matrons' rounds

2- Nurse management rounds

3- Patient comfort rounds

4- Teaching rounds

-1-nurse matrons' rounds

Matrons' rounds, which can provide senior nurses with the opportunity to achieve key
aspects of their role. These include ensuring professional and clinical nursing standards,
improving infection control

-2-nurse management rounds

This round involve the nurse in charge of the shift seeing each patient. And it gives the
nurse manager an overview of the condition and needs of all the patients on the wards and the
ability of staff to meet these needs. Also these rounds have potential benefits for patients,
relatives, for the nursing team and for other healthcare professionals.

-3-patient comfort rounds (pcrs)

(pcrs )are an important part of maintaining and monitoring the fundamental aspects of
individual patient care. They should be carried out at 2-hour intervals whenever possible,
commencing after lunchtime and continuing for the rest of the day.

At night time, pcrs should be carried out before patients go to sleep and again in the
early morning. It may be necessary to carry out more regular care to some patients.

The purpose of pcrs is to maintain a regular review of the patient nursing needs, support
the nursing process and evaluate nursing care.
-4-teaching rounds

Nurses learn in a variety of ways: through courses and accredited programs, seminars,
conferences, self-directed study and so on. One of the most effective ways, however, is to
participate in special clinical teaching rounds.

These are aimed at all learners, whether pre-registration students or qualified staff.
Teaching round is to learn from direct patient contact with facilitation from an experienced
nurse teacher. And also to teach and evaluate nursing care. It is useful in developing clinical
practice, evidence-based care.

Bedside clinic

Bedside teaching is a vital component of medical education and one of the most
effective ways to learn clinical and communication skills. Evidence-based studies show that
interpersonal and communication skills of doctors have a significant impact on patient care.
 Bedside teaching is defined as teaching in the presence of a patient. Generally, it is
thought that bedside teaching is applicable only to the hospital setting.
However, bedsides teaching skills apply to any situation where the teaching occurs in the
presence of a patient, including an office setting and long-term care facility.
Sir William Osler (1849-1920), a renowned clinician-teacher, put emphasis on the
importance of bedside teaching. In 1903 he stated “To study the phenomena of disease without
books is to sail an uncharted sea, whilst to study books without patients is not to go to sea at
all.”
Sylvius (1614-1672), a French practitioner after whom the ‘Sylvian Fissure’ was named,
was one of the first to record his thoughts on teaching on rounds. He said that to lead students
by hand to the practice of medicine, it was necessary to make them see patient every day and
get back the symptoms and physical findings. He also inquired from the students regarding
their observation, thought and perceptions related to the patients’ illness and the principles of
treatment.”9
As opposed to listening to a presentation or reading off a blackboard, teaching in the
presence of patients allows the learners to use nearly all of their senses such as hearing, vision,
smell and touch to learn more about the patient.
Here are many skills, particularly the humanistic aspects of medicine, which cannot be
taught in a classroom. A comprehensive physical examination can provide 70% diagnosis, while
56% of the diagnosis is derived only from a patient's history. 
The Importance of Bedside Teaching
By providing a chance for asking relevant question to obtain history and develop
physical examination skills in a sympathetic manner, teaching at the bedside presents an
excellent opportunity for the modeling of professional behaviors.
It provides active learning in real context, observes students' skills, increases learners'
motivation and professional thinking, integrates clinical, communication, problem solving,
decision making and ethical skills, and improves patients' understanding
Reasons for Declining Bedside Teaching
The most important reasons for the decline of bedside teaching are time constraint due
to pressure to see more patients with increased record keeping, shortened hospital stays of
patients,22 and preceptors’ worry about patient comfort.
In addition, faculties' unworkable expectations, lack of confidence or experience,
uncomfortable role of the bedside teacher, learners’ distraction by technology, and others' low
recognition of the role lead to the decline in bedside teaching.
The general feeling about bedside teaching is that there is erosion of the teaching
ethics, devaluation of teaching, and a great deal of unobtainable skills
Despite the belief that bedside teaching is the most effective method to teach clinical
and communication skills, the frequency of bedside rounds is decreasing. It is believed that this
is a major factor causing a sharp decline in trainees' clinical skills.

Case presentation 

A case presentation is a formal communication between health care

professionals (doctors, pharmacists, nurses, therapists, nutritionist etc.) regarding a patient's
clinical information. Essential parts of a case presentation include:

 Identification
 Reason for consultation/admission
 Chief complaints (CC) - what made patients seek medical attention.
 History of present illness (HPI) - circumstances relating to chief complaints.
 Past medical history (PMHx)
 Past surgical history
 Current medications
 Allergies
 Family history (FHx)
 Social history (SocHx)
 Physical examination (PE)
 Laboratory results (Lab)
 Other investigations (imaging, biopsy etc.)
 Case summary and impression
 Management plans
 follow up in clinic or hospital
 Adherence of the patient to treatment
 Success of the treatment or failure.
 Causes of success or failure.

Patient Care Conference

Care conferences are held for every person receiving health care at home or in a care
facility. They help the “care team” ~ everyone involved in the person’s care ~ share information
and work together to meet the person’s needs.
Think of it this way: A hiker needs a map. A builder needs a floor plan. A shopper needs a
list. People who provide health care are the same. To do their best, they need a “care plan” for
the person they’re caring for. A care plan tells:

 what the needs are

 what the team’s goals are for meeting those needs
 What steps are planned to meet those goals.

Patient Care Conference (Family conference for patients who lack decision-making
capacity with the patient's medical power of attorney representative or health care surrogate
and others the representative/surrogate asks to attend)

1. Introduce meeting participants - if you did not get a chance to introduce yourselves
to the patient/family before the meeting, explain the role of the ethics committee, and give the
family a chance to bring someone for support (clergy), and ask questions - do so at the
beginning of the meeting. Everyone introduces themselves and their role. (Make sure someone
grabs a box of tissues to bring into the meeting.)
 2. The team provides an update on the patient's medical condition (physicians, nurses,
therapists). Input from the bedside nurse is very helpful to understand the patient's functional
level, degree of pain and suffering, and expressed wishes.

3. The family is given the opportunity to ask questions about the medical condition and
to talk about their concerns and values.

4. Identification of patient's values and preferences, if known.

5. The team presents possible options.

6. If the patient's values and preferences are known, select option that the patient
would want.

7. If patient's values and preferences are unknown, discuss the patient's best interests.

8. If the patient's interests are unclear, do a time-limited trial of therapy with clear
endpoints defined.

9. At the end of the meeting, summarize agreement, describe what the family can
expect, and explain their role in subsequent decision making.

10. Set time for follow-up meeting if needed.

Who Is On the Care Team

In care at home or in a nursing facility, a care team includes:

 The patient or resident, who is the most important person on the team.

 Family, when the person asks them to come ~ or if the person needs help.

 The doctor, who is in charge when it comes to medical care.

 Nursing staff, who provide nursing and personal care.

 Social work staff, who help meet emotional and social needs.

 rehab staff (physical, occupational, speech therapy), who help set and meet goals for
getting back or holding on to as much function and independence as possible.

 In a nursing facility, the care team also includes:

 Activities staff, who help meet the need for an active life.

 Dietary staff, who plan the kind of meals the person needs and wants.

Are Care Conferences Important?

 They help make sure there is a team approach to care.

 They help make sure everyone providing care has the facts they need.

 They help make sure everyone understands three key things: the person’s needs; the
goals set up to meet those needs; and the plan for reaching the goals.

 Clinical pathway

 clinical pathway, also known as care pathway, integrated care pathway, critical

pathway, or care map, is one of the main tools used to manage the quality in healthcare
concerning the standardization of care processes.

 It has been shown that their implementation reduces the variability in clinical
practice and improves outcomes.

 Clinical pathways aim to promote organized and efficient patient care based

on evidence-based medicine, and aim to optimize outcomes in settings such as acute
care and home care. A single clinical pathway may refer to multiple clinical guidelines on
several topics in a well specified context.

Characteristics
Clinical pathways (integrated care pathways) can be seen as an application of process
management thinking to the improvement of patient healthcare. An aim is to re-center the
focus on the patient's overall journey, rather than the contribution of each specialty or caring
function independently. Instead, all are emphasized to be working together, in the same way as
a cross-functional team.
More than just a guideline or a protocol, a care pathway is typically recorded in a single
all-encompassing bedside document that will stand as an indicator of the care a patient is likely
to be provided in the course of the pathway going forward; and ultimately as a single unified
legal record of the care the patient has received, and the progress of their condition, as the
pathway has been undertaken.
 The pathway design tries to capture the foreseeable actions which will most commonly
represent best practice for most patients most of the time, and include prompts for them at the
appropriate time in the pathway document to ascertain whether they have been carried out,
and whether results have been as expected.
In this way results are recorded, and important questions and actions are not
overlooked. However, pathways are typically not prescriptive; the patient's journey is an
individual one, and an important part of the purpose of the pathway documents is to capture
information on "variances", where due to circumstances or clinical judgment different actions
have been taken, or different results unfolded.
The combined variances for a sufficiently large population of patients are then analysed
to identify important or systematic features, which can be used to improve the next iteration of
the pathway.

Selection criteria

The following signals may indicate that it may be useful to commit resources to establish
and implement a clinical pathway for a particular condition:

Prevalent pathology within the care setting

Pathology with a significant risk for patients

Pathology with a high cost for the hospital

Predictable clinical course

Pathology well defined and that permits homogeneous care

Existence of recommendations of good practices or experts opinions

Unexplained variability of care

Possibility of obtaining professional agreement

Multidisciplinary implementation

Motivation by professionals to work on a specific condition

Examples