Educational Opportunities and Barriers to Learning During Post-Take Ward Rounds. A Systematic Review.

doi:10.21203/rs.3.rs-4895745/v1

Background: Bedside teaching is essential to medical education and is considered an effective method for teaching technical and nontechnical skills. The post take ward round (PTWR) is often the first review of patients’ presentations, diagnoses, and management plans and serves as a teaching forum. Although PTWRs are vital in inpatient care, their educational values remained under-researched. This review aims to identify educational opportunities and barriers to learning during PTWRs.

Methods: The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search was conducted in bibliographic databases, PubMed, Medline, the Cochrane Library, Scopus Web of Science, the Cumulative Index to the Nursing and Allied Health Literature (CINAHL), Embase, PsycINFO, and Google Scholar, and 14 articles were identified and appraised by the Medical Education Research Study Quality Instrument (MERSQI). A modified Kirkpatrick's framework was used to guide data extraction. Themes about learning were identified, integrated, and presented in evidence tables.

Results: The highest and lowest MERSQI scores for individual studies were 13.5 and 6.5, respectively. The MERSQI mean score for the included studies was 10.08 (SD 1.82). Thirteen studies (92.8%) reported Kirkpatrick’s level 1(Reactions), 12 (85.7%) reported level 2 (knowledge, skill, and attitude), 7 (50%) reported level 3 (Behaviour), and only 2 (14.2%) reported level 4 (outcomes). Clerking and presentation, using pre- and post-round times for discussions, questioning, demonstration, and active participation, were perceived as educational opportunities. However, time pressures, workload, a lack of feedback, and inadequate preparation and engagement are barriers to learning.

Conclusion: PTWRs are opportunities to learn nontechnical skills. They improve knowledge and skills related to diagnostic tests and care escalation. Learning during PTWRs requires preparation, engagement, attention to active participation, a feedback culture, role modelling, and team structure.

Post take ward rounds

ward rounds

learning

teaching

opportunities

barriers

medical education

Bedside teaching is essential to medical education and has been considered an effective method of teaching technical and nontechnical skills. Ward rounds (WRs) are defined as complex clinical practices during which the care plans of hospitalized patients are reviewed (Royal College of Physicians of London, 2015). Several types of WRs are described in the literature, such as post-take ward rounds (PTWRs), working rounds, teaching rounds, and generalized rounds; although their primary purposes are variable, they focus mainly on the decisions made by leading clinicians (Bibi et al., 2022). Traditionally, WRs are educational platforms for learning clinical and interpersonal skills (Khalaf and Khan, 2022). Combined with evidence-based knowledge, these skills are cornerstones of clinical decision-making and for reaching most diagnoses without reliance on diagnostic tests (Laskaratos et al., 2014), which enhances professional competencies and improves patient outcomes, the ultimate goal of medical education (Kalet et al., 2010). Bedside teaching focuses on real-world problems where senior clinicians model trainee thinking, behaviors, and attitudes (Baker et al., 2016).

Workplace learning is primarily informal, unintended, and opportunistic. Understanding the theories underpinning learning on WRs helps maximize learning. Social constructivist theory views learning as a shared rather than an individualized process in which students develop their knowledge, skills, and attitudes while engaging in community activities. In Kolb’s learning model, students reflect on concrete experiences to build and consolidate abstract concepts, apply conceptual understanding, and test it in new situations to gain more concrete experiences. Despite the model’s relevance to workplace learning, it views learning as an individualized process. Situated cognitive theory assumes that learning and thinking are influenced by the settings and tools available in particular situations, highlighting the need for different teaching approaches (Kavitha et al., 2015). Conceptualizing how learning occurs in the clinical environment is complex. Self-directed learning is one aspect of medical education and Andragogy principles. It requires trainees to take the initiative to identify learning needs, create learning goals, find resources for learning, and constantly evaluate learning outcomes. Despite the efforts of educators to adopt this concept, trainees are rarely entirely autonomous and usually require supported learning, such as involving trainees in patients’ care, setting learning objectives, offering feedback, and encouraging independent learning (Dong et al., 2021). Miller’s pyramid explains how trainees learn from WRs and develop their knowledge, skills, and attitudes from novice to expert levels. For example, trainees start by gathering facts (knowing), interpreting facts (knowing-how), progressing to demonstrate what they have learned (showing), and integrating performance into practice (doing) (Reece and Kalber, 2012). WRs are examples of legitimate peripheral participation. In other words, junior doctors (JDs) can start by observing and performing simple, low-risk tasks and become total participants as their knowledge and skills grow.

Participation during WRs depends on space available for trainees through formal and informal invitations to address questions and discussions and practice history-taking and examination skills (Jaye et al., 2009). Space varies depending on the doctor’s training stage and the suitability of clinical circumstances, such as presentation type and acuity. Overall, engagement in patient management is believed to influence trainees’ perceptions of the educational value of WRs (Dewhurst, 2010; Khalaf and Khan, 2022).

PTWRs are initial encounters between clinicians and patients, often in the first 12-24 hours after presentation, where problem lists are identified, provisional diagnoses are made, and healthcare plans are outlined (Dewhurst, 2010). They are often initiated by junior team members and facilitated by consultants. They involve managing patients with a wide range of clinical presentations, providing a unique learning environment that offers exposure to complex clinical scenarios, life-threatening presentations, and challenging situations. Additionally, they provide opportunities for collaboration and teamwork. However, the educational value of PTWRs is influenced by many factors, including trainee learning objectives and the training stage, individual enthusiasm, which drives teaching and learning; WR structures; and approaches and workload (Stanley, 1998).

The literature describes time pressures, workloads, schedule interruptions, the service-oriented nature of WRs, divergent learner needs, large teams, or overly detailed discussions between clinicians as overt learning barriers, as well as a lack of feedback, questioning, and engagement with teaching (Jaye et al., 2009; Khalaf and Khan, 2022). Cognitive overload and a lack of competence in bedside teaching are also barrier to learning (Laskaratos et al., 2014). In acute clinical settings, the shift from trainee- to consultant-based reviews improves patient flow but makes learning from patient reviews negligible. The restriction in working hours prevents trainees from presenting their work from previous shifts to consultants, with no precise mechanism for feedback to the initial assessing team (Chaponda et al., 2009). Additionally, seniors rarely attend trainee-patient interactions, which have troubled workplace-based assessments during WRs (Chaponda et al., 2009; Dewhurst, 2010). The balance between service provision and teaching should be considered, and service work should complement learning rather than interfere with it; furthermore, the effective integration of service, experience, and learning can maximize educational opportunities (Stanley, 1998). Cooperation among teachers, trainees, and patients allows effective teaching while maintaining workflow. A lack of engagement by these stakeholders can significantly disrupt the learning process (Khan et al., 2021). Clinicians should facilitate learning by consciously and actively involving trainees in patient care by utilizing handover time for discussions, encouraging trainees to ask questions, paying attention to multidisciplinary team discussions, explaining what is being discussed, demonstrating clinical skills, and facilitating case-specific teaching (Dewhurst, 2010; Jaye et al., 2009; Khalaf and Khan, 2022). Planning WRs is beneficial for learning; for example, planning teaching timing, allowing trainees to review patients independently before WRs, and choosing convenient times for discussions are perceived to enhance learning (Khan et al., 2021). However, there is ambiguity about the educational value of PTWRs, and a knowledge gap exists regarding the educational opportunities they offer medical trainees and what factors may influence them. This highlights the need for a literature review to describe, appraise, analyze, and synthesize the results from existing primary studies addressing the learning opportunities and barriers to learning among PTWRs.

1.2. Study Aims and Objectives:

The study aimed to summarize, appraise, and synthesize the results of eligible studies to identify learning opportunities and barriers to learning among PTWRs. Identifying learning opportunities and obstacles can provide valuable information and aid in understanding the educational value of PTWRs.

The study was conducted to answer the following research questions:
1-What are medical trainees’ and students’ educational opportunities during medical and surgical PTWRs?
2-What are the barriers to learning during PTWRs, from teachers’ and trainees’ perspectives?

3-What are trainees’ perceptions of the educational value of PTWRs?

2.1. Study Design:

This systematic literature review adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to transparently report the rationales, steps, and study results (Page et al., 2021).

2.2 Inclusion and Exclusion Criteria:

The study inclusion criteria were as follows:
• The study population included medical students, medical-profession trainees, and residents at all training stages.

• Educational interventions include medical and surgical PTWRs.

• Outcomes: The primary outcomes are learning opportunities and barriers; the secondary outcomes are trainees' perceptions of education during PTWRs.

The exclusion criteria were as follows:
• Studies describing learning opportunities and barriers in medical ward rounds other than PTWRs.
• Studies related to learning in nonclinical settings, such as online, computer, and simulation-based learning, and those conducted in primary care settings.

• Studies published in languages other than English.

2.3. Search Strategies:

A literature search of published articles was conducted on major bibliographic databases, such as PubMed Medline, the Cochrane Library, Scopus Web of Science, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PsycINFO Databases and Google Scholar, to identify the primary studies describing the learning opportunities and barriers associated with PTWRs. A search of relevant article references was also conducted to identify additional eligible studies. The search terms included: trainees, residents, students AND post take, acute round, AND learning, teaching, NOT online-based learning, simulation, computer-based learning, primary care, and free text: post take ward rounds, postgraduate medical education, educational opportunities, and learning barriers (Newman and Gough, 2019). The search limiters of English language publications and publications in peer-reviewed journals narrowed the search.

2.4 Study Selection:

First, studies were retrieved from the search process by screening the titles and abstracts of each article (preliminary screening) to consider articles relevant to the review. Duplicate articles and those not deemed relevant to the review were excluded. Second, articles were assessed for eligibility after the full texts were read, and inclusion and exclusion criteria were applied. When the inclusion or exclusion of an article was questionable, the issue was resolved through discussion with the coauthor.

2.5 Data Extraction and Analysis:

Relevant data were collected from each eligible study via a data extraction form. The data collected included the author, institute, country, year of publication, study population characteristics (stages of training), methodological characteristics (sample size, sample frame, study design, response rate), and reported outcomes (Table 1).

The modified framework of Kirkpatrick’s model was used to guide data analysis, synthesis, and reported outcomes. The model is deemed suitable for review because it provides information for evaluating educational interventions and describing expected learning outcomes. The reported learning outcomes included the following: 1) reactions (trainees’ views on learning experiences and their participation and engagement in learning during PTWRs); 2) learning (knowledge, including knowledge gained from discussions; skills acquisition, including history-taking and physical examination skills; and attitudes, including attitudes toward PTWRs, use of team approaches and collaboration); 3) behavior (impacts of PTWRs on trainees’ behavior; and nontechnical skills of situation awareness, leadership, and prioritization of tasks); and 4) results (improved trainee performance and patient outcomes) (Oandasan and Reeves, 2005). The data from individual studies were organized into evidence tables and integrated to answer the review questions. The data were analyzed and presented in a descriptive and qualitative style, and no formal quantitative assessments were made.

1.6 Quality Assessments of Studies:

The Medical Education Research Study Quality Instrument (MERSQI) was used to appraise the quality and methodological rigor of the included studies (McLean and Schwarz, 2023). The instrument contains ten items reflecting six domains: study design, study sampling, type of data, validity of evaluation instrument, data analysis, and outcomes. Each domain had the same maximum score of three, with a total maximum score of 18, which reflected the highest quality (Asmri, Haque and Parle, 2023). The instrument is suitable for this review because it provides a reliable tool for appraising the methodological quality of medical education research; however, the scores should be interpreted using item-specific codes rather than overall scores. Because different research questions mandate different study designs, the scores should be used for relative rather than absolute judgments (Cook and Reed, 2015).

A total of 608 articles were retrieved from the search; 596 were from bibliographic databases, and the other 12 articles were identified by searching the websites and reference lists of retrieved articles (grey literature). After removing duplicate studies (n=79), 529 articles remained. First, the titles and abstracts of the 529 studies were screened to identify eligible articles. A total of 421 articles were excluded because they did not provide information about the research questions. A total of 108 articles were assessed for inclusion and exclusion criteria; 94 studies were excluded for the following reasons: review (n=4), audit (n=3), or other studies that were irrelevant to educational intervention (n=87). Fourteen articles that met the minimum inclusion and exclusion criteria were used for qualitative synthesis. The steps involved in the article search and selection process are summarized via the PRISMA flow chart (Figure 1).

3.1 Study Characteristics:

The designs, characteristics, participants, settings, and reported outcomes for each included study are summarized in Table 1. Of the 14 studies included, 12 were conducted in the United Kingdom, and one each was conducted in Australia and Canada. Most of the studies, 10 (71.4%), were conducted in single institutions and UK district hospitals (DHs), with the largest study (Naqvi) involving data collection from 274 participants across 36 UK centres.

In terms of the time scale, most of the studies, 13 (92.8%), were published between 2011 and 2021, with only one (7.2%) published in 1998 (Stanley). Thirteen articles studied learning in actual WRs, while one study was conducted as a part of situational learning sessions. There was some variability in terms of design; 11 (78.5%) studies were single-group cross-sectional or single-group post-test studies only. Only one study had a single group with a pre-and post-test design. The remaining two studies had qualitative descriptive and evaluative designs. Ten studies involved trainees at diverse training levels, ranging from medical students to higher specialty trainees (HSTs); however, only 5 (35.7%) considered teachers’ perceptions of education during PTWRs.

3.2. Study Quality:

The data were gathered from eligible articles and grouped into an extraction form to inform the assessment, guided by the MERSQI instrument. The highest and lowest scores for individual studies were 13.5 and 6.5, respectively. Two studies had qualitative designs and could not be assessed by the MERSQI instrument. The remaining 12 studies had a MERSQI mean score of 10.08 (SD 1.82). Five (41.7%) studies did not report the response rate. Details of the individual studies and MERSQI item scores are shown in Table 2.

Table 1. Study characteristics, designs, participants, descriptions, and reported learning outcomes (sorted alphabetically).

Source	Study design	Participants/ population	Descriptions	Outcomes (Kirkpatrick’s levels)
Bhangu and Hartshorne, 2011	Prospective observational study	Data was collected from the medical records of 52 patients.	A study over a four-week period to investigate how often admission diagnoses are changed after PTWRs and how it impacts educational feedback in trainees’ absence.	1
Caldwell, 2013	Single group, cross-sectional	100> 300 students and doctors from different grades	An evaluation of formative assessments during PTWRs and their impacts ON learning, over a nine-year period.	1,4
Chau et al., 2011	A descriptive qualitative study with thematic content analysis	18-Acute care physiotherapist clinical instructors	A study across four acute hospitals in Toronto to understand the opportunities and challenges to IPE from a physiotherapist clinical instructors’ point of Views. The average number of years worked in acute settings was 8.5.	1,2,3
Claridge, 2011	Single group cross-sectional	33>53 FY doctors 14>27 medical registrars	A study to explore the educational value of WRs from both trainees’ and trainers’ perspectives. FY doctors participated in a median of four (range 2–5) consultant or SpR-led ward rounds per week, an average of 10.5 hours per week over six months.	1,2
Dewhurst, 2010	Single group post-test only	22- JDs, from foundation year doctors, senior house officers and specialty registrars	A Study to explore JDs’ learning experience on Post Take Ward Rounds.	1,2,3
Force, Thomas and Buckley, 2014	Single group pre and post-test	18> 25 -Medical students 5/10 Consultants	A study to identify the perceived learning barriers to undergraduate teaching and evaluate the impact of CTFs’ support on PTWRs. The trainees participated in PTWRs at least once a week over five weeks.	1,2
Hayden et al., 2021	Single group Post-test only	14>26 -CTFs and FY doctors. (10 were CTFs)	An investigation of how CTFs supported WRs Influenced undergraduate teaching during acute takes.	1,2,3
Laskaratos, Parry and El-Mileik, 2016	Single group cross-sectional	14>18-HSTs from different medical specialties.	An exploration of specialty trainees’ perceptions of PTWRs to understand learning opportunities and barriers and identify suggestions for improvement. Average, most respondents participated in one PTWR per week.	1,2,3
Levett and Caldwell, 2014	Single-group cross-sectional	18> 25 medical registrars.	The study was conducted through a questionnaire-based survey in a DH to seek SpRs’ opinions on using structured approaches such as checklists and their influence on leadership training during PTWRs. Every SpR experienced between one and 15 (median seven) PTWRs.	1,3,4
Modak and Gray, 2020	Single group post-test only	20-junior doctors	This article examined junior doctors’ perceptions of education and feedback on WRs over nine months.	1,2
Naqvi et al., 2012	Single-group, post-test only	274>297 Foundation year-1 doctors	A study compared the impact of different clinical activities (including PTWRs) on FY1 doctors’ knowledge; and how it is influenced by changes in key working practices.	1,2
Reece and Kalber, 2012	Descriptive evaluative	90 pediatricians from across the UK and Ireland	Facilitated groups were selected from a pediatric educational program (PEP); during the program, the participants worked in small groups to consider learning and teaching ward rounds as part of situational learning sessions.	1,2,3
Shah and Kneebone, 2019	Single group post-test only	12/12 -Junior doctors: foundation year doctors and higher surgical trainees.	A study was conducted in a DH to investigate the barriers to learning during the PTWRs. It utilized semi-structured interviews and adopted a constructivist stance and grounded theory approach.	1,2,3
Stanley, 1998	Prospective observational study	24 trainers: two-thirds are consultants, and one-third are SpRs.	A study across four hospitals in the Anglia region was conducted to observe 90 WRs over one year and explore how a change in WR structures can maximize learning opportunities.	1, 2

Table 2. Medical Education Research Study Quality Instrument, domain, and mean scores for selected studies.

Domain	MERSQI Item		Item Score	Max.Domain Score	Studies, n (%)	Mean score.
Study Design				3		1.04
	Study Design
	a.	Single-group cross-sectional or single-group post-test only	1		11 (91.6)
	b.	Single group pre and post-test	1.5		1 (8.4)
	c.	Non-randomized, 2 group	2		0 (0)
	d.	Randomized controlled experiment	3		0 (0)
Sampling				3		0.66
	Institution
	a.	Single institution	0.5		10 (83.3)
	b.	Two institutions	1		0 (0)
	c.	More than two institutions	1.5		2 (16.7)
	Response rate					0.58
	a.	Not applicable	n/a		5 (41.6)
	b.	Response rate<50% or not reported	0.5		2 (16.7)
	c.	Response rate 50-74%	1		3 (25)
	d.	Response rate >75%	1.5		2 (16)
Type of data				3		1.5
	a.	Assessment by study subject	1		9 (75)
	b.	Objective measurement	3		3 (25)
Validity of evaluation instruments` scores				3
		Not applicable
Internal structure						0.91
a.		Reported	1		11 (91.)
b.		Not reported	0		1 (83.3)
Content						0.75
a.		Reported	1		9 (75)
b.		Not reported	0		3 (25)
Relations to other variables						0.5
a.		Reported	6		6 (50)
b.		Not reported	0		6 (50)
Data analysis				3
	Appropriateness of analysis					1
	a.	Data analysis inappropriate for study design or type of data	0		0 (0)
	b.	Data analysis appropriate for study design and type of data	1		12 (100)
	Sophistication of analysis					1.33
	a.	Descriptive analysis only	1		8 (66.6)
	b.	Beyond descriptive analysis	2		4 (33.4)
Outcome				3
	Outcome					1.79
	a.	Satisfaction, attitudes, opinions, general facts, perceptions	1		1 (8.3)
	b.	Knowledge, skills	1.5		5 (41.7)
	c.	Behavior	2		4 (33.4)
	d.	Patient/health outcome	3		2 (16.6)
Total				18		10.08

3.3 Identified Themes, Data Analysis and Qualitative Synthesis:

3.3.1 The Educational Value and Perceptions of Learning During PTWRs:

Thirteen studies (92.8%) reported on Kirkpatrick’s level 1 (Reactions), 12/14 (85.7%) reported on level 2 (knowledge, skill, and attitude), 7/14 (50%) reported on level 3 (behavior), and 2/14 (14.2%) reported on level 4 (outcomes). Of the 14 articles included, only 2 referred to educational concepts (theories) underpinning learning from WRs. Both studies (Shah and Kneebone, 2019; Reece and Kalber, 2012) referred to social constructivist theory, and the latter referred to situated cognitive theory.

Level 1 Outcomes (Reactions). Thirteen studies reported on students’ and trainees’ exposure frequency and engagement with PTWRs (Table 1), and only one study (Bhangu and Hartshorne, 2011) was based solely on data from medical records.

Participation and Engagement with PTWRs. One study (Laskaratos, Parry and El-Mileik, 2016) investigated the perceptions of PTWRs among HSTs. On average, most respondents (n=11) participated in one PTWR session per week, while a few (n=2) participated in two per week, and one participated daily. It was reported that senior clinicians were interested in teaching; however, trainees found creating and maintaining personal relationships with the consultants challenging. A total of 9/14 (64%) of the trainees described having opportunities to ask questions during the PTWRs; however, 29% reported never being asked questions during the rounds. This issue was further explained by Dewhurst’s study, which reported that foundation year (FY) doctors described asking questions as stressful because most of the time they were busy performing other tasks. Notably, in the same study, specialty registers (SpRs) demonstrated higher levels of engagement as individuals were asked and allowed to ask questions.

Naqvi and colleagues investigated engagement in various learning activities and the impact of these activities on FY doctors’ knowledge during PTWRs. The study revealed that 160/274 (58.4%) of the participants had attended PTWRs, accounting for only a small proportion; 23/274 (8.4%) of the doctors had clerked patients; and 11 (4.0%) of them had done both.

The results also revealed that among the 8.4% of the FY doctors who had clerked patients and the 58.4% who had participated in the PTWRs, their knowledge of the patients whom they were looking after was significantly greater than that of their peers who did not have the opportunity to attend these activities.

Two studies (Caldwell, 2013; Levett and Caldwell, 2014) referred to innovation and the use of sign-in forms to acknowledge participation and ensure team members’ engagement with PTWRs. The latter study assessed the impacts of structured approaches, such as checklists, on SpRs’ learning and leadership training when SpRs experienced between one and 15 (median seven) PTWRs led by general medicine consultants. The former study evaluated the formative assessment processes used during PTWRs, in which 100 students and doctors who participated experienced the processes over nine years.

Shah and Kneebone’s (2019) study assessed trainees’ engagement with formative assessments when they explored JDs’ perceptions of learning during PTWRs. All participants were engaged in formative assessment and used rounds for benchmarking against trainers’ and peers’ expectations; they consistently undertook reflective practices to enhance learning. The most senior trainees demonstrated active participation by questioning, learning by doing and learning by teaching. Moreover, more junior doctors, such as FY doctors, have adopted passive learning approaches such as observation, repetition, and instruction.

Hayden et al. (2021) examined the experience of JDs in supporting undergraduates’ education in acute takes. The participants were aware of the role of active participation in experiential learning. However, there were perceptions of suboptimal student engagement due to the inconsistency of medical students' attendance on PTWRs. Another study (Force, Thomas, and Buckley, 2014) explored how JDs in formal educational roles, such as clinical teaching fellows (CTFs), can support regular teaching activities for undergraduate medical students. The study reported that medical trainees and students participated in PTWRs at least once a week over five weeks. In Stanley’s study, 90 WRs were observed over a year to explore various approaches to understanding teaching strategies to maximize learning and improve on-the-job teaching. PWTRs were described as avenues for learning among different WRs. In Claridge’s study, the FY doctors participated in a median of four (range 2–5) consultant or SpR-led ward rounds, averaging 10.5 hours per week over six months. However, when WRs became prolonged, teaching became less exciting. The 2020 study (Modak) examined JDs’ perceptions of education and feedback during WRs over nine months. It was agreed that consultants’ engagement in teaching was crucial for establishing a learning culture, and the time they spent doing WRs significantly influenced teaching opportunities. Additionally, trainee perceptions of feedback are influenced by consultant factors (educational engagement), trainee factors (proactivity in seeking feedback), and structural factors (organizational constraints).

Only four studies reported on trainers’ participation (Chau; Claridge; Modak; Stanley), and only one considered the involvement of other health care professionals, such as physiotherapists (Chau et al., 2011). The latter studied interprofessional education (IPE) from a physiotherapist clinical instructor’s point of view. Most participants reported that clinical

IPE must be more consistent, structured, and formal. A few participants expressed concerns

about the clinicians’ engagement with IPE, which may be attributed to their busy schedules.

Trainees’ and Trainers’ Satisfaction and Views on Learning Experiences. Thirteen studies (Caldwell; Chau; Claridge; Dewhurst; Force; Hayden; Laskaratos; Levett; Modak; Naqvi; Reece; Shah; Stanley) reported trainees’ and trainers’ satisfaction and views on the learning experience during PTWRs. Force et al. (2014) reported that the mean enjoyment score for CTF-supported rounds was 9.46, whereas the standard enjoyment score was 4.44. Students tended to learn more about CTF-supported WRs, with a mean score of 9.63, than about standard WRs, with a mean score of 4.06. Medical students enjoyed CTF-supported WRs significantly more than standard rounds did, and WRs supported by CTFs reported increased student enjoyment (p < 0.0001) and perceived learning (p < 0.0001). Furthermore, 100% of the consultants agreed that PTWRs offered learning opportunities for medical students and felt that CTF support was valuable. A second study (Dewhurst, 2010) revealed that students at various stages of training enjoy learning during PTWRs. The senior trainees recognized the benefits of observing specialty consultants practicing in areas outside their fields. The JDs were motivated to present their clerking and obtain feedback from the consultants despite the consultants’ tendency to obtain the information from the clinical notes rather than listening to the trainees’ case presentations. Overall, trainees were aware of the consultants’ influence as role models but were uncertain whether the consultants had the same awareness. Furthermore, trainees felt that their involvement in PTWRs was valuable; however, the benefits of learning opportunities would improve with fewer work tasks. In Caldwell’s study, the trainees’ views of formative assessments were variable. A total of 56% of the respondents reported that formative assessments were very helpful (4-point Likert scale, where 5 is very helpful) to their professional development, 42% reported that they were moderately helpful, and 1% described them as having no effect. Interestingly, 36 (90%) medical trainees acknowledged the benefits of clinical supervisors’ initiative toward formative assessments, as the trainees were less comfortable asking for the assessments. The study reported that for 12 months, 69% of the trainees reported uniformly positive responses to formative assessments.

Levett and Caldwell explored trainees’ views on the influence of using considerate checklists during PTWRs. They reported that seventeen of the 18 (94%) trainees felt that exposure to the checklists had changed their thinking about conducting PTWRs and influenced their practice. According to one study (Laskaratos, Parry and El-Mileik, 2016), most medical trainees felt that PTWRs were focused on service delivery rather than teaching, and 50% of participants felt that little time was devoted to teaching. Only 7% of the participants reported learning something new and received feedback on their performance on every PTWR (5-point Likert scale, where 5 is on every PTWR). Similarly, only 7% of them described changes to their initial admission diagnosis and management plans for every PTWR. JDs found their attachments to acute takes valuable and recognized the broad range of educational opportunities they had during PTWRs. Team structures may impact learning opportunities, and PTWRs may offer teaching opportunities when led by specialty consultants rather than a general physician or permanent rather than locum consultants. A study by Hayden et al. (2012) reported similar findings among trainees, where PTWRs were perceived to be more educative when led by specialty consultants than by general physicians. The participants thought that PTWRs were valuable for learning; however, owing to variations in service demands, assigning time for teaching can be challenging and impact their learning experiences.

Shah and Kneebone summarized individual and systemic barriers that influence learning in the acute environment, such as staff shortages, heavy clinical workloads, changes in shift patterns, and poor trainee-trainer relationships. JD stated that PTWRs are valuable but often miss educational opportunities. Another study (Modak and Gray, 2020) reported trainees’ perceptions of learning and feedback during WRs. It was reported that learning opportunities increase when the culture of feedback changes; doctors become more consistent with and relaxed about feedback. Some trainees felt that feedback was offered only when something had gone wrong. When no feedback was offered, trainees misinterpreted the lack of feedback as a positive assessment of their performance. However, when constructive feedback was offered and perceived as an opportunity for professional development, it was valued, received positively, and was unlikely to be disregarded. Formal structured and sit-down feedback experiences toward the end of clinical placements were valued by all participants; nevertheless, for some participants, this was the only feedback they received during their attachments. Additionally, trainees appreciated the opportunities to hear the consultants explain their thinking and the rationale behind clinical decisions. Learning by being involved in decision-making and guided by the consultants was also valued, as was the consultants’ ability to instruct JDs and other medical professionals at various training stages to reach their learning outcomes. Furthermore, some trainees perceived that consultants were likely to teach more in the presence of medical students. They stated that cognitive overload and lack of direct observation might impact their learning experience. Some participants attempted to explain cognitive overload and how it interferes with learning. The factors attributed to cognitive overload included the timing of teaching and the number of tasks trainees had left to manage. Compared with the other doctors, the JDs described uncertainty about their clinical skills and abilities. SpRs also identified a degree of uncertainty about knowledge, some of whom felt that they needed more confidence in teaching medical students. Despite available educational opportunities, attending educational activities was perceived to be limited by clinical workload, inconsistent teaching time, and frequent interruptions during education sessions. Reece and Kalber (2012) described several ideas for maximizing learning, such as having consistent teaching approaches on WRs, utilizing trainees’ diverse experiences to explore innovative ideas for learning, planning learning, taking the initiative in learning, and seeking feedback and collaboration. Chau and colleagues emphasized the role of collaboration in interprofessional education (IPE) in acute care. Trends have pointed to the importance of interprofessional collaboration (IPC) in IPE; however, collaboration varies according to clinical setting; access to other health care professionals; and time, support, and team structure. Understanding education as a lifelong process should not result in underestimation of students’ preparedness as a prerequisite for clinical IPE.

A study by Stanley (1998) concluded that teaching is a feature of all WRs, whether led by consultants or fellow trainees or whether they were teaching or business rounds. However, it was apparent that “teaching rounds” were more convenient for medical students (undergraduates), whereas “business rounds” were more suitable for JDs (postgraduates). In another study (Claridge, 2011), FY doctors reported that a median of 18% (range 0–50%) of their learning occurs during WRs. However, only a median of 9% (range 0–20%) of average WRs were devoted to education. In contrast to trainees, trainers reported that a median of 20% of their WRs were dedicated to teaching (range 5–30%). The variance can be explained by either the teachers overrating the values of their teaching or the trainees considering that some activities were not learning opportunities. Only 36% of the FY doctors in this study considered WRs to have a good learning experience; 90% of the FY doctors and 100% of the SpRs strongly agreed or agreed (5-point Likert scale, where 5 is strongly agreed) that WRs could become a better learning experience. There were perceptions that WRs were becoming shorter and that clinical decisions were becoming more reliant on diagnostic tests instead of clinical assessments. The FY doctors outlined the traits of clinical educators, such as being enthusiastic about teaching (82%), being approachable (55%), conducting WRs at a reasonable pace (94%), offering quality feedback, and allowing rapport to grow among the team.

Level 2 (knowledge, skills, and attitudes):

Knowledge. Ten studies (Claridge; Dewhurst; Force; Hayden; Laskaratos; Modak; Naqvi; Reece; Shah; Stanley) reported on knowledge acquisition during PTWRs; nine were based on self-assessments, and only one study involved trainees’ knowledge tests. Laskaratos and colleagues reported that PTWRs were beneficial or extremely beneficial for conveying medical knowledge in only 5/14 (36%) HSTs (4-point Likert scale, where 4 is extremely beneficial). In Claridge’s study, ninety-one percent of FY doctors strongly agreed or agreed (5-point Likert scale, where 5 is strongly agreed) that WRs provide opportunities to learn about patient management. Only one study (Naqvi et al., 2012) involved a knowledge test, providing overt statistical evidence and elaboration on this outcome. The study assessed and compared the knowledge gained from PTWRs and other related clinical activities and considered how changes in work patterns can influence knowledge. The study compared PTWRs with other clinical activities, such as clerking, using handover sheets, having sole patient responsibilities for more than 24 hours, and sharing clinical responsibilities with peers. Doctors who clerked patients and attended PTWRs were associated with better median test scores. Having complete responsibility for the patients and knowing them for longer than 24 hours had little influence on the scores. Doctors who had opportunities to admit and clerk patients and attend PTWRs were associated with the best scores and narrower interquartile ranges (IQRs) than were those who did not clerk or attend PTWRs, even if they had full responsibility for the patients and knew them for more than 24 hours; for example, the study revealed that 22/23 (95.7%) who clerked the patients, correctly answered questions related to history, whereas only 110/251 (43.8%) who were not involved in clerking, did so. Interestingly, 132/160 (82.5%) of the participants on the PTWRs were able to provide correct answers to questions related to patient aspects of care, such as those related to thromboembolism prophylaxis, whereas only 64/114 (56.1%) of those who did not attend acute take did so. The role of handover sheets was described as complex. They contributed to getting the answer right to 33.3% of the questions and wrong to 66.7%. Additionally, the scores of 67.2% of the trainees who used handover sheets were significantly lower than those who did not (p = 0.001).

Shah and Kneebone reported variations in the knowledge gained during PTWRs. The most JDs, such as the FY doctors, gained basic medical knowledge and clinical skills during the PTWRs. In contrast, core and higher-level trainees gained decision-making, organizational, and leadership knowledge and benefited from bedside evidence-based patient management discussions. This resembled Dewhurst’s finding when he emphasized the medical knowledge gained from the discussions after seeing each patient. The participants recognized the importance of Consultants’ loud thinking for learning, enabling the trainees to understand the consultant’s clinical thought processes and reasoning.

Two studies (Force, Thomas, and Buckley, 2014; Hayden et al., 2021) focused on the involvement of CTFs and their influence on medical students’ learning. The former study described the role of CTFs in teaching, providing direct contact for medical students and discussing care aspects from students' points of view, which may enhance students’ learning experience and have the potential to improve patient care. The latter study revealed that CTFs were less confident in targeting topics for discussion due to the wide range of clinical presentations in acute settings. It was also described that discussions and direct questioning had a mild to moderate learning yield; when they were used, they required students’ engagement and led to interruptions of WRs. However, they guaranteed students’ active participation. The reluctance of the JDs to participate in discussions was attributed to their uncertainty about the consultants’ expectations and what level of knowledge they were supposed to have. Frequent changes in schedules led to a lack of follow-up of cases and a lack of continuity for trainees to be attached to teams or with consultants, creating challenges in establishing reports between consultants and JDs and masking trainees’ understanding of consultants’ expectations in terms of knowledge, skills, and attitudes. Changes in team structure significantly impact the establishment of raptors and the creation and maintenance of relationships between learners and teachers; the issue of team structure has also been highlighted in two other studies (Caldwell, 2014; Dewhurst, 2010; Levett; Modak and Gray, 2020).

Pre- and post-ward round sessions provide opportunities to learn about diagnoses and management. Discussions can be structured and conducted away from patients to encourage trainee participation. It was found that preround sessions were trainee-centered, as they allowed case presentations, enabled consultant input before and after seeing the patients, and avoided the need for discussions and debates during the WRs themselves, thus allowing the team to focus on service delivery and patient relations (Stanley, 1998). A study by Recce and Kalber (2012) revealed that using “flying solo” rounds was beneficial for enhancing trainees’ knowledge during their placements. The round can be left to the trainees who are ready to “act up” and who then report to the consultants. This approach promotes trainee autonomy; however, it can be limited by the acuity of patient presentations.

Skills. Seven studies (Cadwell; Chau; Claridge; Dewhurst; Hayden; Laskaratos; Levett) reported the benefits of PTWRs in the acquisition of clinical skills. In one study (Laskaratos, Parry and El-Mileik, 2016), 5 respondents described PTWRs as beneficial or highly beneficial (4-point Likert scale, where 4 is highly beneficial) for acquiring history-taking skills (36%), 3 for physical examination skills (21%), 7 for diagnostic skills (50%) and 7 for patient management (50%).

According to the (Claridge, 2011) study, only 4 (28%) trainees agreed that WRs are opportunities to learn examination skills, and only 36% agreed that WRs are opportunities to practice history-taking skills. However, 76% strongly agreed or agreed (5-point Likert scale, where 5 is strongly agreed) that WRs are opportunities to learn and interpret diagnostic investigations. This was supported by Bhangu’s study, which described PTWRs as good opportunities for reviewing diagnostic test results.

Various approaches to acquiring clinical skills were explored by Hayden et al. (2021), who reported that observing clinical skills has a minimal effect on students’ learning and can be adopted only in urgent settings. Additionally, active involvement and support of independent practices result in compelling learning experiences and outcomes; however, these approaches are inconvenient for patients with high acuity. Furthermore, active involvement and direct

observation of clinical skills, coupled with feedback, were found to have a high student learning yield; however, these approaches are more time-consuming than the former approaches are.

Levett and Caldwell described how innovative approaches such as mental and written checklists impact attitudes toward PTWRs, as they promote the value of team members’ inclusion, ascertain roles and responsibilities, set expectations, and enhance communication. However, there were clear trends in which the skills necessary to conduct WRs would be acquired through experiences, observing consultants, and, to a lesser extent, peers. A study by Chau et al. (2011) described clinical instructors reporting the benefits of having students follow their leads in “cotreating and coassessing” patients requiring occupational therapists’ input, particularly for frail patients who are not amenable to extensive therapy sessions. Dewhurst’s study supported the importance of demonstrating clinical skills when 100% of the residents described seeing the consultants take histories and examining patients as valued learning opportunities.

The role of workplace-based assessments in acquiring clinical skills has not been fully elucidated. Only one study (Cadwell, 2013) evaluated the role of formative assessments in learning in acute settings. It was reported that 10 (26%) of the doctors described the formative assessment process as leading to significant improvement (4-point Likert scale, where 4 is a significant improvement), 21 (54%) as having slight improvement and 8 (20%) as having no impact on their ability to list differential diagnoses and clinical problem-solving skills. In comparison, 31 (78%) reported that note-keeping had improved, and 9 (22%) indicated that it had no effect.

Attitude. Seven studies reported this outcome (Chau; Dewhurst; Force; Laskaratos; Modak; Navqvi; Reece). A study by Naqvi et al. (2012) reported that 206/274 (75.2%) FY doctors shared clinical responsibilities with their peers, whereas 68 (24.8%) had sole responsibility.

Doctors who shared clinical responsibilities were associated with higher scores on knowledge tests and had a higher p value (0.143) than did those who only attended PTWRs (0.001) or only clerked patients (< 0.001).

The trainees’ attitudes during WRs play a crucial role in their learning journey; for instance, active engagement in questioning (Dewhurst, 2010; Laskaratos, Parry and El-Mileik, 2016) has been proven to increase the acquisition of knowledge and skills. Trainees’ traits, such as taking the initiative to seek feedback, active participation in questioning, self-awareness, and reflection, are pivotal for learning new skills (Chau et al., 2011; Modak and Gray, 2020). On the other hand, attitudes such as overcrowding, a lack of enthusiasm among students, and consultants’ unapproachability and tendency to rush rounds may hinder learning and interfere with teaching (Force, Thomas, and Buckley, 2014). The trainers’ attitudes and the strategies they adopt for teaching are equally important in promoting learning. The consultants’ teaching strategies, which can maximize learning, may include encouraging trainees’ engagement in reflective practice, capturing small educational moments and utilizing them to share valuable pearls of information with students, stimulating discussions by questioning, and using post-round time for discussions and feedback on trainees’ clinical decision-making (Modak and Gray, 2020). However, attitudes toward PTWRs vary among trainers. It was perceived that the ways in which PTWRs were approached differed from their approaches to other clinical activities, such as outpatient clinics (Dewhurst, 2010).

PTWRs enable the modeling of consultations, collaboration and interactions with other medical professionals and service users (Reece and Kalber, 2012). This view is supported by Chau’s study, which revealed that clinical IPE thrives with more IPC. For example, trainees can attend rounds and start with observation and progress to learn collaboration and teamwork.

Overall, the quality of interprofessional learning is determined by the degree of interaction between team members.

Level 3 (Behavior). Seven studies reported this outcome (Table 1). Laskaratos and colleagues reported that 8/14 (57%) medical trainees reported that PTWRs were beneficial or highly beneficial (using a 4-point Likert scale, where four is highly beneficial) for developing skills such as complex decision-making related to the escalation of care and nontechnical skills such as communication, time management and leadership skills. In one study (Levett and Caldwell, 2014), the use of considerate checklists positively influenced trainees’ behaviors and enhanced skills such as leadership. However, Hayden et al. (2021) considered it challenging to learn nontechnical skills, which can be taught through coaching and close tutor observations. Four studies (Chau; Dewhurst; Laskaratos; Reece) described the power of consultants’ behaviors as a learning motivator. For example, consultants’ abilities to demonstrate constructive and challenging approaches, direct team members in inconvenient situations, explain their thought processes, offer feedback, demonstrate their approaches toward patients and colleagues within a multidisciplinary team, and inspire trainees to emulate their examples can profoundly impact trainees’ behaviors. PTWRs enable the assignment of specific roles, for instance, by allowing core and higher trainees to act up and enhance their leadership, teamwork, communication, delegation, and organization and gain decision-making skills (Reece and Kalber, 2012; Shah and Kneebone, 2019).

Level 4. Results (improved patients’ outcomes). Only two studies have reported this outcome (Caldwell, 2013; Levett and Caldwell, 2014). The first study (Levett and Caldwell, 2014) described using checklists during PTWRs as helpful in managing avoidable patient harm, and most participants (16/18 [88%]) reported changes in practice after their exposure to checklists. In the second study (Cadwell, 2013), the process of formative assessment was found to have diverse effects on trainees’ clinical performance. A considerable proportion (4, 10%) reported a major improvement (4-point Likert scale where 4 is a major improvement), a definite improvement (24, 60%), or a slight improvement (12, 30%). However, only 14 (35%) reported that their prescribing had improved safely, 23 (58%) reported that it had improved, and 3 (7%) reported that it had no effect.

3.3.2 Themes of Learning Opportunities:

All 14 studies reported on learning opportunities during PTWRs. Eleven studies (Chau; Claridge; Dewhurst; Force; Hayden; Laskaratos; Levett; Modak; Reece; Shah; Stanley) described the utilization of pre-rounds, post-rounds and handover times for discussions and learning, such as picking up clinical findings or diagnostic test results and making them focus on teaching, in addition to case-specific learning and evidence-based patient management discussions. Nine studies highlighted the value of questioning (Claridge; Dewhurst; Force; Hayden; Laskaratos; Modak; Reece; Shah; Stanley), for example, when trainees take the initiative in learning and ask direct questions or when trainers allow the students to offer their answers during or after the rounds. When trainees are asked questions, the questions can be tailored according to the grade and responsibility of the learner “Stratified Learning Rounds”. Patient clerking (Hayden et al., 2021; Naqvi et al., 2012) and presentation of clinical work (Dewhurst, Modak, Stanley) offer a chance to practice clinical skills and learn by doing.

Eleven studies (Bhangu, Caldwell; Claridge; Dewhurst; Force; Hayden; Laskaratos; Levett; Modak; Reece; Stanley) discussed the educative aspects of feedback. Actively seeking feedback from senior clinicians reflects trainees’ proactivity and motivation for learning. It gives them insight into their practice, helps them understand teachers’ expectations, and offers opportunities to reflect on performance to consolidate learning (Chah; Chau; Modak).

Feedback should be instant, constructive, specific, descriptive, and consistent to achieve its educative purposes.

Four studies (Chau; Dewhurst; Laskaratos; Reece) described the importance of consultants’ behaviors as role models and their influences on learning. The consultants’ demonstration of clinical approaches to patients in challenging situations, history-taking and physical examination skills (Dewhurst, 2010; Laskaratos, Parry and El-Mileik, 2016), thinking aloud, explaining the thought process, and providing rationale for medical decision-making may benefit trainees’ learning experiences (Dewhurst; Laskaratos; Modak).

Eight studies (Chau; Dewhurst; Force; Hayden; Laskaratos; Levett; Reece; Shah) described how medical students and JDs benefit from observing senior colleagues and, to a lesser extent, from peers practicing different clinical approaches to a wide range of clinical presentations in acute takes; therapy; enhancing trainees’ clinical skills such as teamwork, collaboration, communication, and delegation.

Six studies (Caldwell; Hayden; Laskaratos; Levett; Reece; Shah) reported on the role of active participation in creating learning opportunities. Active involvement with specific responsibility allocation allows for the practice of various technical and nontechnical skills; additionally, direct observation of trainees’ performance offers valuable chances for formative assessment (assessment for learning) and appraising trainees’ practices with feedback. Modifying PTWR approaches may allow those ready to act up to actively participate in WRs and acquire the skills required for independent practice. A mental and written checklist can guide the process to ensure adequate preparation and enhance trainees’ leadership and communication skills (Levett and Caldwell, 2014). Two studies (Force Thomas and Buckley, 2014; Hayden et al., 2021) highlighted the role of JDs in supporting the teaching of medical students through PTWRs. The intervention was perceived to increase students' enjoyment and improve learning.

PTWRs are opportunities for gaining experience in difficult decision-making, such as those related to resuscitation and the ceiling of care (Laskaratos, Parry and El-Mileik, 2016). They are also useful in interpreting and learning diagnostic investigations (Bhangu; Force; Laskaratos; Stanley).

Table 3. Themes pertaining to learning opportunities.

Article (Authors, year)	Discussions	Questioning	Clerking	Presentation	Feedback	Role modelling	Observation and demonstration	Active participation	Workplace- based assessments	Consultant`s loud thinking
Bhangu and Hartshorne , 2011	-	-	-	-	✔	-	-	-	-	-
Caldwell, 2013	-	-	-	-	✔	-	-	✔	✔	-
Chau, et al., 2011	✔	-	-	-	-	✔	✔	-	-	-
Claridge, 2011	✔	✔	-	-	✔	-	-	-	-	-
Dewhurst, 2010	✔	✔	-	✔	✔	✔	✔	✔	-	✔
Force, Thomas and Buckley, 2014	✔	✔	-	-	✔	-	✔	-	-	-
Hayden et al., 2021	✔	✔	✔	✔	✔	-	✔	✔	-	-
Laskaratos, Parry and El-Mileik, 2016	✔	✔	-	-	✔	✔	✔	✔	✔	✔
Levett and Caldwell, 2014	✔	-	-	-	✔	-	✔	✔	-	-
Modak, and Gray, 2020	✔	✔	-	-	✔	-	-	✔	-	✔
Naqvi et al., 2012	-	-	✔	-	-	-	-	-	-	-
Reece and Kalber, 2012	✔	✔	-	-	✔	✔	✔	✔	✔	-
Shah and Kneebone, 2019	✔	✔	-	-	-	-	✔	✔	✔	-
Stanley, 1998	✔	✔	-	✔	✔	-	-	✔	-	-

3.3.3 Themes Pertaining to Learning Barriers:

A total of eleven studies (Bhangu; Caldwell; Chau; Claridge; Dewhurst; Force; Hayden; Laskaratos; Modak; Reece; Shah) assessed barriers to teaching during PTWRs. Among the recurring themes, eight studies (Chau; Claridge; Dewhurst; Force; Hayden; Laskaratos; Modak; Reece) reported time constraints and working hour limitations. Seven studies (Chau; Claridge; Dewhurst; Hayden; Laskaratos; Modak; Reece; Shah) reported on the multiple tasks, and unpredictable nature of the acute takes as barriers to learning. Six studies (Chau; Claridge; Force; Hayden; Laskaratos; Modak) highlighted the suboptimal engagement of trainees and teachers with educational activities as learning obstacles. The lack of engagement may be attributed to the unavailability of consultants for teaching doctors and other health care professionals and the variability of students’ presence during PTWRs (Chau; Force; Hayden).

Seven (50%) studies (Table 4) outlined the issue of inconsistent team structure and its influence on learning. The frequent rostering, reliance on locum doctors, and variations in students’ placements, which often do not coincide with those of other disciplines, have led to difficulties in establishing rapport or creating relations with teachers and frequently led to missing collaborative experiences (Chau; Claridge; Laskaratos; Shah). Furthermore, in the presence of staff shortage, changing shift patterns also leads to frequent rostering (Claridge; Hayden; Modak; Shah) to meet the service demands, lowering the trainees’ chances of attending PTWRs, presenting their clinical work and clerking (Bhangu; Dewhurst; Laskaratos), following patient progress, and understanding diagnostic test results and their implications (Bhangu and Hartshorne, 2011; Laskaratos Parry and El-Mileik, 2016). Additionally, trainees have rarely been observed interacting with patients and multidisciplinary team members (Modak and Gray, 2020; Dewhurst, 2010) or receiving feedback on their clinical performance (Bhangu; Laskaratos; Modak). When available during the rounds, they were rarely asked or had opportunities to ask questions (Claridge; Dewhurst; Laskaratos). PTWRs occurring imminently after admission reduce trainees’ chances of instituting care plans and reduce their autonomy (Dewhurst, 2010). There was a tension between clinical service provision and teaching (Claridge; Laskaratos; Modak; Reece; Stanley) and integrating clinical and educational roles. The Influence of senior doctors on teaching cultures reinforces the belief that teaching is a secondary activity (Hayden et al., 2022), a factor that may contribute to reducing formal and informal time devoted to educational activities and viewing PTWRs focused on service rather than teaching (Claridge, 2011; Laskaratos, Parry and El-Mileik, 2016). Furthermore, senior clinicians could have been more approachable and available to support teaching activities and collaborative interactions with other health care professionals (Chau et al., 2011; Force, Thomas, and Buckley, 2014). Other teacher factors are reliance on the information retrieved from the clerking and admitting sheets with often no clinical reasoning, referring to clinical notes to obtain clues about patients’ presentations without listening to trainees’ presentations or opinions (Dewhurst, 2010), reliance on diagnostic test results rather than clinical findings from the history and examination to conclude diagnoses, and therapy depriving the trainees of valuable opportunities to learn clinical skills. Additionally, non specificity and inconsistency of feedback (Claridge, 2011; Laskaratos Parry and El-Mileik, 2016) and inflexibility and inconvenient timing, such as using afternoon WRs for teaching (Chau et al., 2011; Claridge, 2011), may hinder learning. Other learning barriers include suboptimal induction and preparation of medical students and inadequate understanding of their learning needs (Chau; Dewhurst; Hayden). Trainees’ uncertainty about their knowledge and consultants’ expectations may also contribute to missed opportunities to use feedback for learning. They often interpret the lack of feedback as a positive assessment of their performance or misunderstand the intention of the feedback and assume that feedback is offered only when something has gone wrong (Modak and Gray, 2020).

Finally, a decline in remuneration for teaching (Shah and Kneebone, 2019) and suboptimal support for clinical instructors and junior doctors in formal educational roles may lead to a lack of interest or confidence in delivering teaching sessions (Chau et al., 2011; Hayden et al., 2021). Additionally, there were difficulties in targeting topics for teaching due to the complexity of cases, and scarcity of organizational resources such as computers, physical spaces and the tendency to direct them to service delivery rather than education (Hayden et al., 2021); and environmental factors such as frequent interruption, and background noise (Dewhurst; Force; Laskaratos; Reece).

Table 4. Themes pertaining to learning barriers.

Article (Author, year)	Time constraints	Multi-tasks and unpredictable work	Environment (interruptions and noises)	Lack of preparation	Change in team Structure	Lack of engagement	Lack of follow-up of cases/ feedback/ Feedback culture	Lack of questions	Unawareness of learning needs & expectations	Organisations ; focus on service. / Resources
Bhangu and Hartshorne, 2011	-	-	-	-	-	-	✔	-	-	-
Caldwell, 2013	-	-	-	-	-	-	-	-	-	-
Chau, et al., 2011	✔	✔	-	✔	✔	✔	-	-	-	-
Claridge, 2011	✔	✔	✔	-	✔	✔	--	✔	✔	✔
Dewhurst, 2010	✔	✔	-	✔	-	-	✔	-	-	-
Force, Thomas and Buckley, 2014	✔	-	✔	-	-	✔	-	-	-	-
Hayden et al., 2021	✔	✔	-	✔	✔	✔	-	-	✔	✔
Laskaratos, Parry and El-Mileik, 2016	✔	✔	✔	-	✔	✔	✔	✔	-	✔
Levett and Caldwell, 2014	-	-	-	-	-	-	-	-	-	-
Modak and Gray,2020	✔	✔	-	-	✔	✔	✔	-	✔	✔
Naqvi et al., 2012	-	-	-	-	-	-	-	-	-	-
Reece and Klaber, 2012	✔	✔	✔	-	✔	-	-	-	-	-
Shah and Kneebone, 2019	-	✔	-	-	✔	-	-	-	-	-
Stanley, 1998	-	-	-	-	-	-	-	-	-	✔

Ward rounds were originally intended to manage patient care and provide a means to educate medical trainees. Little evidence of learning opportunities and barriers during WRs exists in the literature. The review analyzed the available literature on this topic from the United Kingdom, Australia, and Canada.

The review demonstrated that PTWRs provide learning opportunities for medical trainees; however, no previous reviews on their educational value have been published. This review applied a modified Kirkpatrick framework to guide data acquisition and to report learning outcomes from PTWRs as an educational intervention. Overall, participants in all included studies perceived PTWRs as learning opportunities; however, 2 out of 14 studies also reported trainee enjoyment. PTWRs improve trainee knowledge; for example, 10 out of 14 studies reported on knowledge gained from discussions; however, nine were based on self-assessments. Additionally, in 7 out of 14 studies, participants considered the rounds valuable for improving trainees’ skills, attitudes and behavior. The review revealed that 2 out of 14 studies reported Kirkpatrick level 4. This may reflect a design issue, as the outcomes were not considered when qualitative data were obtained.

There is convincing evidence of learning barriers during WRs. One review examined the perceptions of education during WRs; it included 23 studies and identified time pressure, workload, inconsistent schedules, frequent interruptions, and service-oriented natures. A lack of feedback, lack of engagement with patient management, and divergent learning needs are significant learning barriers (Khalaf and Khan, 2022). One of the strengths of this review is its reliance on data from recently published articles; however, it is limited by the prominence of qualitative data among the included studies. Another systematic review (Laskaratos et al., 2014) explored the educational value of WRs in conveying knowledge and skills. This study summarized the learning barriers identified in 22 studies and categorized them into systemic, environmental, and teacher-related factors. Moreover, cognitive overload and a lack of teacher competence are barriers to effective bedside teaching. This study addressed an under researched topic in the literature; however, it did not adopt a particular approach to reporting learning outcomes.

This review demonstrated how learning barriers are integrated and related to each other, and no single factor is attributed solely to missing learning opportunities. A few studies have identified suboptimal trainee preparation and inadequate understanding of trainees’ learning needs as learning obstacles. The team structure is of profound importance and influences other factors, constituting the top barrier to learning. With team structure changes, trainees have less time to establish rapport with their teacher, leading to a lack of engagement and confidence in their participation in WR activities, including questioning and participating in discussions. Additionally, it impacts the communication of trainees’ learning needs and masks teachers’ expectations of trainees’ knowledge. A decrease in active trainee participation arrests trainee development and experiential learning, as the habits of questioning, discussions, and acting are essential for knowledge and skill acquisition. Discussions are a platform for sharing knowledge; however, they require teacher facilitation and direction to stimulate further reading (Noorani, 2022). The reluctance to participate in discussions or ask questions is multifactorial. Workload, cognitive overload, and time pressure can influence participation. Choi et al. (2024) assessed these factors and categorized them into learning culture, psychological safety, self-efficacy, and trainees' autonomy.

PTWRs are opportunities to learn nontechnical skills; collaborate; and make challenging decisions, such as those related to the escalation of care and, to a lesser extent, clinical skills such as history taking, physical examination, diagnostic tests and interpretations. This finding reflects the reliance on diagnostic tests, which may have educational, financial, and emotional costs. Doctors’ fundamental clinical skills are deprived, unbalanced use of resources occurs, and the quality of patient care is impacted when doctors become more interested in tests than people are and when false-positive tests arise, leading to unnecessary anxiety and long waiting times (Claridge, 2010). Investing in workplace training foster the ability of physicians to manage critically ill patients and confidence in their ability to be future teachers (Hayden et al., 2021).

The review revealed that discussions and questioning play pivotal roles in gaining knowledge during PTWRs, and they are considered more attractive for trainees than clerking and presentation activities are. Having opportunities to observe demonstrated clinical skills was crucial to workplace learning; however, the themes demonstrated that trainees value active participation, with constructive and routine feedback on their performance. Additionally, the teachers’ ability to think aloud and explain the rationale behind clinical decision-making and their ability to act as role models constituted underestimated learning opportunities.

Learning in a clinical environment is complex. It is not always a measurable product and is not limited to knowledge acquisition; instead, it involves a complex process of gaining knowledge and skills, changing behavior and, importantly, developing attitudes toward patients, which is the most crucial aspect of medicine. We should be aware that the ways we act, significantly impact other individual’s behavior. Although there is no consensus on the definition of role modeling, there is some consensus that it is a positive source of social and educational influence. However, the magnitude of this influence remains uncertain. One systematic review (Passi et al., 2023) described the traits of excellent role modeling as a demonstration of high-quality clinical competencies, excellent clinical teaching, and humanistic individual qualities.

Few studies have considered workplace-based assessments, including formative assessments, as learning opportunities. Formative assessment provides an opportunity for learning through feedback and reflection on performance; however, schedule changes could interfere with the feedback. Despite all the obstacles, capturing educational moments is possible before, during and after the PTWRs. We should not underestimate the role of observation, which helps those in their early careers understand the work environment and gradually develop skills within the team. However, adequate preparation and planning are essential to ensure that trainees are oriented toward work settings and benefit from their attachments to ward rounds.

4.2 Strengths and Limitations:

This review covered an under researched topic following PRISMA guidance to document all the steps. Its limitations include the small number of primary studies, the fact that most of those studies were conducted in one country, and the fact that only some of the studies were multicentered. Most of the related studies have been based on trainees’ views, and few have considered teachers’ perceptions. One researcher conducted the review, and all the articles had qualitative designs. Additionally, given the differences in study designs, it was impossible to compare their results.

4.3. Conclusion:

PTWRs are opportunities to learn technical and nontechnical skills such as leadership, communication, time management, and decision-making and to improve knowledge related to diagnostic tests. To a lesser extent, they enhance history-taking and examination skills. Despite educational opportunities, many potential barriers interfere with effective teaching, and they can be considered integrated parts of the problem rather than individual factors. Institutions should work to eliminate factors that affect team structures and ensure adequate preparation for trainees at the beginning of their attachments. Second, senior clinicians should consider trainees’ learning needs and encourage students’ participation in WRs. Additionally, they need to approach PTWRs similarly to other clinical activities, such as outpatient clinics; consider the balance between service delivery and teaching; and acknowledge their influence as role models. There is a need to change the feedback culture and increase awareness of available learning opportunities at all levels, trainees, teachers, and organizations.

4.4. Recommendations:

The reviewer recommends additional multicenter research in this area to explore the educational value of PTWRs, the learning opportunities they can offer, and the learning challenges teachers and trainees might face. Future studies should consider trainers’ views. Additionally, additional research is needed to explore the educational value of PTWRs for other health care professionals, such as nurses and clinical pharmacists.

CI: Clinical instructor

DH: District Hospital

FY: Foundation Year

HST: Higher Specialty Trainee

IPC: Interprofessional Collaboration

IPE: Interprofessional Education

JD: Junior Doctor

ME: Medical Education

MERSQI: Medical Education Research Study Quality Instrument

OJT: On-the-job teaching

PEP: Pediatric Educational Program

PRISMA: Preferred Reporting Items for Systematic Review and Meta-Analysis

PTWR: Post-taking Ward Round

SpR: Specialty Registrar

WR: Ward Round

Ethics approval: Ethical approval was obtained from the Review Board of the Faculty of Life Sciences and Education, University of South Wales, UK.

Consent to Participate: Not applicable.

Consent for Publication: Not applicable.

Availability of Data and Materials: Data supporting the findings of this study is available within this published article.

Competing Interests: None to declare. The research was completed in partial fulfillment of the MSc in Medical Education degree from the University of South Wales, UK.

Funding: No funding was received for this research.

Author Contributions: This was a professional project. The research was conducted by AB and supervised by JB.

Acknowledgments: Many thanks to Jibril Bello, my project supervisor at the University of South Wales.

Referencing: Harvard’s referencing style.

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Competing interest reported. I declare that no conflicts of interest exist. The research was completed in partial fulfilment of MSc in Medical Education degree from the University of South Wales, UK

Educational Opportunities and Barriers to Learning During Post-Take Ward Rounds. A Systematic Review.

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Abstract

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Introduction

Methodology

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