To the best of our knowledge this is the first study analysing the function of WR in paediatric oncology that considers all relevant stakeholders. Altogether we identified four MT, comprising a total of 30 categories. Respondents collectively stated that requirements for a successful WR were not yet standard practice and should be implemented in daily routine.
An essential finding was that 12 out of 13 interviewees defined “emotional support” as one of the main WR functions. It even appeared more often than “handing over information” (mentioned in 11 interviews). Research shows that parents are encouraged by seeing so many different people care for their children [17], and that including families in the discussion process during WR improves the satisfaction of parents and patients [4, 18, 19]. Additionally, collecting information comforts parents of children with cancer [20]. It is a coping mechanism helping people in stressful situations by reducing uncertainty and regaining a sense of control [21, 22]. A recent study exploring parents’ perceptions of ward rounds highlighted that parents highly value it primarily for the opportunity to collaborate with the clinical team and to ask questions [42].
In this study, only patients and nurses described the WR as an opportunity to build and strengthen relationships, while neither parents nor doctors mentioned this. Patients explained that knowing their doctors helped them understand decisions. Decision-making is a complex process and is influenced by personal attitudes, values and beliefs [23]. Understanding how decisions are made helps patients to accept and support the decision and improves their cooperation [24]. Another study showed that a good patient-doctor relationship could reduce the risk behaviour of adolescents with cancer [25]. The fact that this aspect was not mentioned by doctors in the present study suggests that they are not aware of this potential.
Research shows that errors in the treatment of hospitalised children lead to prolonged hospital stays and higher mortality [26, 27]. Sharma et al. [28] identified the WR as a potential source of errors: Bad communication can cause lost, misunderstood or unarticulated information. By contrast, good communication within the team and between doctors and patients can reduce errors [29]. Poor communication can be attributed to the use of medical jargon, apparent time constraints and the lack of empathic change of perspective [43]. Interviewees in our study underlined that they missed structure in verbal exchanges. Doctors raised concerns about potentially missing warning signs. As this is a uniform and global challenge, there are however first attempts to implement guidelines, which reduce error rates, and improve communication [28, 30].
Despite previous research suggesting open and honest communication with families, our study highlights that this is still lacking in practice [31, 32]. We see a need for more open communication, where everything is said explicitly so patients do not have to focus on non-verbal communication.
Our data shows that interviewees would prefer a member of the psychosocial team to attend the WR. In literature, the optimal team composition in WR is not yet defined and often varies [33]. Literature shows that multidisciplinary WR achieve greater patient involvement, improved teamwork and better consideration of patient’s needs than multidisciplinary team meetings [34]. In paediatric oncology, looking after families’ psychosocial concerns can prevent noncompliance [35]. Involving members of the psychosocial team in WR could therefore improve cancer treatment. However, when implementing multidisciplinary rounds, team size has to be considered as our data shows that most patients and parents would prefer smaller WR teams.
Finally, our results indicate that neither professional team members nor families felt well prepared for WR. International research has already revealed that this is not only a problem in Germany, but can be found globally. While communication skills become more important in university education programmes, the WR is not yet part of the curriculum [11]. Recently, research has explored new WR training programmes for healthcare staff [36, 37]. It is striking that many of these are designed for medical students only, despite scientific agreement on teamwork and communication being significant elements of WR [5]. Research shows that interprofessional learning can improve both [38].
Patients of this study unveiled that emotional preparation for WR was challenging. Originally, they were scared of WR, until they understood that it is a daily routine and nothing bad happens necessarily. This goes hand-in-hand with Berkwitt and Grossman’s findings [39], who observed that paediatric patients associate WR with negative feelings when starting treatment. It can therefore be assumed that healthcare staff could spare patients anxieties and insecurity by explaining the purpose of WR early-on, which is consistent with other studies [44].
Little is known about the relevance of different competences in specific disciplines. An interesting study compared relevant competences in surgery and psychiatry by interviewing ward staff and found, not surprisingly, that clinical skills were mentioned more often in surgical interviews, while nonverbal communication was described more often in psychiatric interviews [45]. However, the patients’ or the relatives’ perspectives were not considered. To ensure the best possible doctor-patient communication all relevant perspectives have to be included, as our study demonstrates and explores.
Our study has several strengths and limitations. The interviews provided a realistic understanding of the participant’s experiences and covered a wide range of aspects. However, a limitation inherent to qualitative research is that results cannot easily be generalised. Nevertheless, our data can serve as a base for further research with more respondents to reach greater generalisability.
Our data represents experiences from a single institution. Experiences of members of WR on other oncology wards may differ. However, our study focused on a multidisciplinary team, patients with severe illnesses and their families, emotional and stressful situations, and relationships between different WR members. These aspects can be found in other oncology wards accordingly. We therefore assume that our results have some sort of external validity.
As we could only include interviewees who were able to speak and understand German, our results cannot be generalised to foreign-language speakers and participants with a migratory background as their experience might be different. Language barriers are still a huge problem in healthcare [40]. Social, cultural and religious differences are additional obstacles in the treatment of paediatric patients [41]. As the WR is the central place of communication, these aspects should be examined in future research.
Lastly, we included only a limited number of interviewees. Nevertheless, within this small cohort, maximum diversity was attempted to achieve representation of all major groups participating in WR, work-experience from 1 to 31 years, different genders and age variation. We stopped the recruitment of participants when we reached a theoretical saturation [15].
The amount of literature regarding WR in paediatric oncology is limited, and, to our knowledge, does not cover comparing experiences of all stakeholders. Thus, this study adds substantially to the small but growing body of literature regarding WR in general and in paediatric oncology in particular.