Evaluating the Educational Value of Internal Medicine Ward Rounds: Perspectives of Medical Students and Postgraduate Residents

Evaluating the Educational Value of Internal Medicine Ward Rounds: Perspectives of Medical Students and Postgraduate Residents | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluating the Educational Value of Internal Medicine Ward Rounds: Perspectives of Medical Students and Postgraduate Residents Abdelrahman Hamad¹, Abdel-Naser Elzouki¹, Raneem Alsheikh², Ahmad Hamdan², and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8502082/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Ward rounds remain a central component of clinical education in internal medicine, providing learners with opportunities to observe clinical reasoning, participate in patient care, and develop a professional identity. Despite their importance, the educational value of ward rounds is inconsistently realised, particularly in busy teaching environments where service demands may compete with learning. Methods This qualitative study explored how final-year medical students and internal medicine residents (PGY1–4) experience ward rounds as learning activities. Eleven focus group discussions were conducted with students and residents at a large tertiary teaching hospital in the Gulf region. Discussions were audio-recorded, transcribed, anonymised, and thematically analysed using Braun and Clarke’s framework. Results Four interrelated themes were identified. Ward rounds functioned as powerful learning spaces, allowing learners to integrate theory with practice and progress from observation to clinical participation. Consultant behaviour emerged as the most influential factor shaping the learning environment, with interactive teaching and role modelling enhancing engagement, while task-focused approaches constrained it. Learning was further enriched through peer interaction across training levels and collaboration with allied health professionals. However, service pressures, post-call fatigue, fragmented patient locations, and time-consuming family discussions frequently limited educational continuity. Conclusions Ward rounds remain a vital but underutilised educational resource. Their effectiveness depends less on structure alone and more on how clinical teachers intentionally engage learners during routine care. Supporting faculty development, fostering inclusive participation across learner levels, and recognising common barriers may help clinical educators maximise learning opportunities on ward rounds. Ward rounds clinical teaching workplace learning medical students residents qualitative research Introduction Ward rounds remain a central feature of clinical education in internal medicine, offering learners opportunities to observe clinical reasoning, participate in patient care, and engage in professional dialogue within real clinical settings (Claridge, 2011 ; Laskaratos et al., 2015 ). As routine yet high-stakes activities, ward rounds represent a key interface between service delivery and education, where moment-to-moment interactions, clinical priorities, and supervisory practices shape learning. Early work on bedside ward rounds highlighted their role in fostering experiential learning and clinical engagement across training levels (Gonzalo et al., 2009 ). When effectively facilitated, ward rounds allow learners to integrate theoretical knowledge with clinical practice through observation, participation, and reflection, supporting the development of clinical competence and professional identity (Yardley et al., 2012 ; Cruess et al., 2015 ). However, their educational value is highly variable. Prior studies have shown that competing service pressures, time constraints, and differences in consultant teaching styles can limit learner engagement and reduce opportunities for meaningful participation (Claridge, 2011 ; Gonzalo et al., 2013 ; Noorani, 2022 ). Studies examining learners’ perspectives consistently report that, while ward rounds are perceived as educationally valuable, their learning potential is frequently constrained by efficiency-driven practices (Tariq et al., 2010 ; Eljack et al., 2023 ). Importantly, learners at different stages of training may experience ward rounds differently. Undergraduate medical students often occupy observational or peripheral roles, whereas residents are expected to participate actively in clinical decision-making and patient management. How ward rounds accommodate these differing learning needs and how clinical teachers navigate this complexity in practice remain underexplored. Much of the existing literature examines medical students or residents in isolation, with limited attention to how both groups experience the same ward round environment simultaneously. While these challenges have been described across diverse healthcare systems, contextual factors may further shape ward-round learning. In Middle Eastern teaching hospitals, for example, hierarchical clinical structures, strong family involvement in care discussions, and multicultural clinical teams may influence participation, communication, and teaching dynamics (Helmich et al., 2017 ; Jazieh et al., 2018 ; Taha et al., 2020 ). Understanding how such factors interact with routine ward-round practices can offer relevant insights not only locally but also to other high-volume teaching environments facing similar pressures. This study explores how final-year medical students and internal medicine residents perceive the educational value of ward rounds within a large tertiary teaching hospital. By comparing learner experiences across training levels, the study aims to identify factors that enable or constrain learning during ward rounds and to generate practical insights to support clinical teachers in maximising educational opportunities during routine patient care. Research Aim and Objectives Aim To explore how undergraduate medical students and postgraduate internal medicine residents perceive the educational value of ward rounds and to identify opportunities to enhance learning during routine clinical practice. Objectives To explore learners’ experiences and perceptions of ward rounds as educational activities. To identify barriers and enablers influencing learning during ward rounds. To develop participant-informed recommendations to enhance ward-round teaching for learners at different stages of training. Project Design and Methods Study Design This study employed a qualitative, exploratory design, suitable for investigating underexplored phenomena in which participants’ experiences are central (Creswell & Poth, 2018 ; Ritchie et al., 2014 ; Yin, 2018 ). It explored how medical trainees perceived and constructed meaning from ward-round experiences in a teaching hospital setting. A constructivist paradigm informed the design, viewing knowledge as co-constructed through interaction and reflection (Vygotsky, 1978 ; Dennick, 2016 ). This orientation supported the aim of understanding how learners at different training stages interpreted ward-round learning. Reporting follows the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist (Tong et al., 2007 ). Setting The study was conducted at Hamad General Hospital (HGH), a 600-bed tertiary teaching hospital within Hamad Medical Corporation (HMC) in Doha, Qatar. HGH is the leading internal medicine training site in the country. It hosts the core clinical rotations for undergraduate medical students from Qatar University College of Medicine and residents of the national Internal Medicine Residency Programme. A single-centre design enabled in-depth contextual analysis and control of institutional variables, ensuring consistent structures and culture for cross-level comparisons (Marshall, 1996 ; Creswell and Poth, 2018 ). Participant Recruitment and Sampling Participants included final-year medical students from the Qatar University College of Medicine and internal medicine residents (PGY1–PGY4) enrolled in the Hamad Medical Corporation (HMC) Internal Medicine Residency Programme. Eligible trainees who had recently completed their inpatient internal medicine rotations at Hamad General Hospital were contacted via their respective programme offices shortly after rotation completion. This approach approximated total-population sampling by purposively varying across training levels, consistent with qualitative sampling strategies that aim for maximum variation and contextual depth (Patton, 2015 ). Recruitment occurred within two weeks of rotation completion to maximise recall. Focus groups were organised primarily by training level: three junior-only (PGY1–2), three senior-only (PGY3–4), and three student-only groups, to reduce hierarchical influence and encourage level-specific discussion. Additionally, two mixed groups comprising both junior and senior residents were conducted. Initially, they were for scheduling feasibility, but they proved valuable for capturing cross-level interactions and comparative perspectives. Resident groups consisted of 4–6 participants, and student groups consisted of 4 participants each. We continued recruitment until robust representation was achieved from each participant group. Thematic saturation was confirmed after the ninth focus group, as the final two discussions (one with senior residents and one with students) yielded no new codes or concepts, only repetition and refinement of existing ideas. Recruitment was therefore concluded at this stage. Data Collection Focus group discussions (FGDs) were the sole data-collection method, chosen for their ability to elicit interactive dialogue and reveal both shared and divergent perceptions (Kitzinger, 1995 ; Krueger & Casey, 2015 ). Each 45–60-minute session was conducted face-to-face during protected departmental time in September 2025 and was recorded via Microsoft Teams. A semi-structured guide (Appendix 1) was developed, drawing on experiential and constructivist learning theories (Kolb, 1984 ; Vygotsky, 1978 ; Dennick, 2016 ), to explore learners’ experiences, perceived educational value, enablers and barriers, and suggestions for improvement. To minimise faculty–trainee power dynamics, the FGDs were conducted by trained resident facilitators: two junior residents (PGY1) and two final-year medical students, who had no supervisory or evaluative role over participants and who piloted the guide with the principal investigator (PI) to ensure consistent questioning. The PI observed sessions remotely and passively via Microsoft Teams to ensure methodological consistency across facilitators and reviewed early transcripts to confirm appropriate alignment with the study aims. No field notes were taken; the analysis relied on verbatim transcripts and audio recordings. Ethical approval was obtained from the HMC Medical Research Centre (MRC-01-25-670) and the University of Warwick’s Biomedical and Scientific Research Ethics Committee (REGO-WMS-ME-25.035). Data Management and Anonymisation All FGDs were recorded on the hospital’s secure Microsoft Teams account, with a temporary audio backup deleted after verification. Recordings were transcribed verbatim using a secure speech-to-text service. The PI verified transcripts for accuracy, and an independent second coder reviewed a subset to enhance reliability. Personal identifiers were removed and replaced with participant codes (e.g., J1, S2, F3). Contextual details that could enable re-identification were generalised or omitted to maintain confidentiality. Anonymised data were stored on encrypted institutional servers. They will be retained for ten years in accordance with HMC and University of Warwick policies, after which they will be permanently deleted. Data Analysis Thematic analysis followed Braun and Clarke’s ( 2006 ) six-step framework. The process began with familiarisation, during which the PI read and re-read all transcripts to achieve deep immersion. Initial coding was conducted using NVivo software, supplemented by manual line-by-line coding of selected transcripts to ensure inductive codes remained grounded in the raw data. This hybrid approach enhanced analytical depth and trustworthiness (Saldaña, 2021; Nowell et al., 2017 ). An independent coder double coded a subset of transcripts, and any discrepancies were resolved through discussion and iterative refinement of the codebook. During theme development, codes were collated into candidate themes, which were then reviewed and refined against the coded extracts and the complete dataset to ensure coherence and accurate representation. This iterative process included creating thematic maps and reflective discussions to confirm interpretive consistency. In the defining and naming phase, the essence of each theme was articulated and assigned a concise, descriptive title. Finally, report writing involved selecting vivid, representative quotations to weave the analytical narrative presented in this paper. Trustworthiness and Reflexivity The trustworthiness of the analysis was ensured by addressing Lincoln and Guba’s ( 1985 ) criteria. Credibility was established through data source triangulation—collecting perspectives from students, junior, and senior residents—and through peer debriefing during the analytic process. Dependability and confirmability were supported by maintaining an audit trail of analytical decisions and by double-coding a subset of transcripts, with consensus discussions to refine the codebook. Transferability was enabled through the thick, contextual description of the setting and participants. Reflexivity was maintained through ongoing team discussions regarding preconceptions. To further mitigate the potential influence of the PI's educator-researcher role on participant candour, the PI did not facilitate focus groups and observed sessions remotely to minimise power dynamics. Ethical Considerations The study posed minimal risk. The Institutional Review Board granted ethical approvals at the study site (Protocol ID: MRC-01-25-670) and the University of Warwick BSREC (REGO-WMS-ME-25.035). Participation was voluntary and confidential, with no impact on academic evaluation. After receiving the Participant Information Leaflet (PIL), participants provided written consent. Before each session, facilitators verbally confirmed the recording and the PI's remote, non-participatory observation, assuring participants that the PI could not identify individuals, which encouraged open dialogue. Participants could withdraw by contacting the PI via institutional email until data anonymisation. The PIL included details on well-being services. Results A total of 54 participants took part: 42 residents (24 juniors and 18 seniors, representing 58% of those invited) and 12 final-year students (67% of those invited). Eleven focus groups were conducted: eight with residents (three junior-only, three senior-only, and two mixed) and three with students. Each resident group comprised 4–6 participants, while each student group comprised 4 participants. Table 1 summarises participant demographics and focus-group composition for the three learner groups. Table 1 Participant Characteristics and focus-group composition. Group Invited Participated Male Female Typical group size FGD composition Junior residents (PGY1–2) 48 24 13 11 4–6 3 junior-only FGDs + 2 mixed FGDs Senior residents (PGY3–4) 24 18 10 8 4–6 3 senior-only FGDs + 2 mixed FGDs Final-year students 18 12 5 7 4 3 student-only FGDs (same-level) Overall, participants described ward rounds as a generally positive and valuable learning experience. While some raised mixed or negative aspects, the majority emphasised their central role in clinical education, particularly in bridging theory and practice. Theme 1: Perceived Educational Value of Ward Rounds Ward rounds were consistently viewed as a core site of experiential learning, integrating theoretical knowledge with patient care. Students described rounds as their first authentic exposure to clinical reasoning: “It gives the clinical sense, books will not” (F1). Another noted, “Sometimes we just observe, but even listening to the team discussion helps us understand the reasoning process” (F2). Juniors highlighted the value of structured presentations and opportunities to suggest management plans: “Presenting in SOAP format and suggesting plans helped me think more broadly” (J10). Seniors described a dual role of supervision and decision-making, with learning strongly shaped by consultant style: “Some consultants engage us in decisions; others just want to move fast” (S2). Theme 2: Enablers of Learning Consultant behaviour emerged as the most potent enabler of learning. Participants highlighted the value of being actively involved in assessment and management planning, as well as being asked stimulating questions that modelled expert reasoning: “When they ask challenging questions, it opens discussion and makes us think” (J4). Peer and cross-level learning further enriched the experience. Juniors relied on seniors for immediate feedback, as one noted: “My registrar corrected my notes, that feedback I could use right away” (J6). Seniors, in turn, appreciated input from other professionals, with one stating that “Every team member adds something, pharmacists and fellows teach practical points” (S3). For students, explanations from residents were vital for connecting theory to practice. Structured assessment tools like the Mini-CEX, though primarily designed for evaluation, were often perceived as valuable teaching aids when used consistently, even though their application varied. Creative teaching strategies were also described. One student recounted how a fellow arranged a deliberate bedside teaching exercise: “he took us in and taught us the findings in an OSCE-style format” (F4). Theme 3: Barriers to Learning Despite a generally positive perception, several systemic barriers hindered learning. Workload was the most prominent. Participants described rounds involving lists of more than 20–25 patients as overwhelming, forcing them to prioritise service delivery over education: “Managing a list of more than twenty patients turns the round into pure service, there is no time left for teaching” (J2). The geographical dispersion of patients across wards further reduced time for bedside learning: “In the Acute Medical Assessment Unit (AMAU), it is smoother, but across dispersed wards we lose time and focus” (S5). Rapid turnover also restricted continuity and follow-up: “We could not see outcomes, patients were transferred before we learned from them” (S6). Non-medical overflow cases, such as surgical admissions, provided limited internal-medicine learning value: “We did nothing for those patients; it felt like wasted time” (J3). Social and family issues were described as culturally significant yet emotionally taxing. Residents noted that lengthy family discussions about discharge or care decisions often consumed time, drained energy, and caused mental fatigue: “By the end of those talks, you lose focus for the next patients” (S4). Students also reported difficulty keeping up with the pace of rounds: “Sometimes rounds moved too fast; we could not follow the reasoning or ask questions” (F4). Service pressure on post-call days further reduced learning opportunities: “After 24 admissions, you just focus on discharges, not learning” (S7). Consultant variability influenced the educational atmosphere, with some prioritising efficiency over teaching. Frequent interruptions, such as non-urgent calls or task requests, fragmented concentration and disrupted the learning flow: “Every few minutes someone calls or asks for orders, it breaks the rhythm and the teaching flow” (S8). Theme 4: Suggestions for Improvement Participants proposed several practical ways to enhance the educational value of ward rounds. The most common recommendation was to cap patient numbers at 6–8 per resident or to balance patient loads by complexity, as one respondent suggested: “Six to eight per resident would be reasonable” (J8). They also emphasised geographical localisation of patients and brief pre-round huddles to clarify daily plans: “Even five minutes before the round can be high yield” (S1). Participants valued structured bedside teaching, even on routine cases—“Better to focus on clinical findings, not basic science” (J5)—and strongly preferred real-time verbal feedback: “Verbal feedback on the spot is more useful than the online system” (J7). Engaging residents in management planning was viewed as increasing ownership and learning depth: “When we are asked to suggest management plans, it makes us think like doctors, not just note-takers” (J10). A need for standardised consultant expectations was clear, with one resident noting, "Every consultant has a different style; there should be basic consistency" (J9), a sentiment echoed by a student who found it "confusing when expectations keep changing" (F6). Senior residents also proposed dedicated "registrar-only sessions" to discuss complex cases in more depth (S8). Table 2 summarises the main themes and subthemes identified from the analysis, with illustrative participant quotes that exemplify each theme. Table 2 Summary of Main Themes, Subthemes, and Illustrative Quotes. Theme Subtheme Illustrative Quote (Code) 1. Perceived Educational Value Students as observers “It gives the clinical sense books will not.” (F1) Observing the reasoning process “Sometimes we just observe, but even listening to the team discussion helps us understand the reasoning process.” (F2) Juniors as reporters “Presenting in SOAP format and suggesting plans helped me think more broadly.” (J10) Seniors as decision-makers / supervisors “Some consultants engage us in decisions; others just want to move fast.” (S2) 2. Enablers of Learning Consultant engagement (planning, questioning, modelling) “When they ask challenging questions, it opens discussion and makes us think.” (J4) Peer and cross-level learning “My registrar corrected my notes—that feedback I could use right away.” (J6) Learning from wider team (e.g. pharmacists, fellows) “Every team member adds something—pharmacists and fellows teach practical points.” (S3) Resident explanations for students “When residents explained why certain tests were ordered, it connected theory with practice.” (F3) Structured tools (Mini-CEX, CSR) “If all consultants used them, it would really improve us.” (S4) Creative strategies “We were not allowed to see the patient first… afterwards, he took us in and taught us the findings in an OSCE-style format.” (F4) 3. Barriers to Learning High workload (volume and complexity) “Managing a list of more than twenty patients turns the round into pure service—there is no time left for teaching.” (J2) Case complexity “Three complex patients can overwhelm you more than ten simple ones.” (J1) Geographical dispersion “In AMAU, it is smoother, but across dispersed wards, we lose time and focus.” (S5) Rapid turnover (transfers) “We could not see outcomes; patients were transferred before we learned from them.” (S6) Non-medical overflow cases “We did nothing for those patients; it felt like wasted time.” (J3) Social / family issues (emotional burden) “By the end of those talks, you lose focus for the next patients.” (S4) Fast pace for students “Sometimes rounds moved too fast; we could not follow the reasoning or ask questions.” (F5) Service pressure (post-call) “After 24 admissions, you just focus on discharges, not learning.” (S7) Consultant variability “Some consultants focus on education, others just want to get through quickly.” (S8) Interruptions “Every few minutes someone calls or asks for orders—it breaks the rhythm and the teaching flow.” (S9) 4. Suggestions for Improvement Capping patient numbers “Six to eight per resident would be reasonable.” (J8) Geographic localisation “If patients were closer together, we would waste less time.” (S1) Pre-round huddles/sitting rounds “Even five minutes before the round can be high yield.” (S1) Structured bedside teaching “Better to focus on clinical findings, not basic science.” (J5) Real-time feedback “Verbal feedback on the spot is more useful than the online system.” (J7) Engage residents in management planning. “When we are asked to suggest management plans, it makes us think like doctors, not just note-takers.” (J10) Standardisation of consultant expectations “Every consultant has a different style; there should be basic consistency.” (J9) / “It is confusing when expectations keep changing.” (F6) Registrar-only sessions “Dedicated registrar sessions would let us discuss complex cases in more depth.” (S10) Across all themes, participants recognised ward rounds as a vital but inconsistently realised educational opportunity. Consultant behaviour, service pressures, and contextual constraints strongly shaped the learning experience. Suggested improvements emphasised structure, feedback, and equitable teaching across training levels, highlighting both shared and stage-specific learning needs. Discussion This study explored students' and residents' perceptions of the educational value of internal medicine ward rounds in a large Middle Eastern teaching hospital. The findings align with international studies that emphasise the role of supervisor engagement and structured teaching (Claridge, 2011 ; Laskaratos et al., 2015 ; Gonzalo et al., 2013 ). However, our cross-level comparisons extend this understanding by revealing how the impact of consultant behaviour, service pressures, and unique contextual constraints differs across the training continuum. These findings are crystallised into several key themes, elaborated below. The Educational Value and Developmental Trajectory Across learner levels, participants viewed ward rounds as the most genuine and valued learning space, essential for situated learning, clinical reasoning, and bridging theory with practice. This process reflects learning through participation in real clinical activity and legitimate professional practice (Lave & Wenger, 1991 ; Dornan et al., 2019 ). For students, rounds served as an initiation into authentic clinical reasoning, learning how doctors think rather than merely what they know. Juniors described gaining fluency in documentation and structured presentation, while seniors emphasised decision-making and leadership. These findings illustrate a scaffolded developmental trajectory—from observer to reporter to decision-maker—aligned with Vygotsky’s ( 1978 ) zone of proximal development. Comparable hierarchies have been identified in grounded-theory studies of postgraduate ward-round learning, where participation progressively shifts from peripheral to central as learners gain confidence and contextual understanding (Noorani, 2022 ; Wazir & Pandita, 2025 ). However, our cross-level data reveal that this progression is not automatic; it is highly contingent on consultants who actively create "zones of proximal development" by calibrating their support to each learner's stage. For students, this means making reasoning explicit; for seniors, it means ceding decision-making authority. This highlights a critical implication: without intentional faculty mediation, the inherent educational structure of the ward round may fail to realise its developmental potential. Consultant Influence & Learning Climate The consultant’s teaching style was the strongest determinant of educational yield, often outweighing case complexity (Khalaf & Khan, 2022 ; Noorani, 2022 ). Supportive consultants who engaged learners through questioning, explanation, and feedback cultivated psychologically safe environments (Edmondson & Lei, 2014 ), whereas directive or efficiency-driven styles restricted dialogue. Observational data indicate that fewer than one-fifth of ward-round interactions involve explicit teaching (Kilian et al., 2024 ), underscoring untapped potential. Our findings confirm that even brief modelling or questioning episodes generated high-impact learning moments. Articulating reasoning or inviting residents to justify plans fostered engagement, while abrupt decision-making promoted passivity. This influence underscores the need for structured faculty development. Evidence from targeted faculty development initiatives demonstrates that hospitalist teaching behaviours during routine clinical work can be enhanced through focused interventions without prolonging ward rounds or compromising service efficiency (Caputo et al., 2023 ). Interventions such as BEDSIDE2-R, which organises bedside encounters around observation and feedback (Nelson et al., 2025 ), and the One-Minute Preceptor model, which supports rapid formative teaching (Vick & Ragsdale, 2023 ), have enhanced teaching frequency without extending round duration. Participants in our study similarly advocated for embedding consistent elements of discussion, reasoning, and formative feedback across teams, rather than leaving them to individual consultant style. Enablers of Effective Learning Beyond the consultant's paramount role, three key enablers emerged: peer and cross-level interactions, interprofessional contributions, and the strategic use of structured tools. Peer and cross-level learning were consistent enablers, with juniors benefiting from observing seniors’ reasoning and students drawing confidence from supportive team dynamics. This collaborative problem-solving aligns with the participatory model of professional education (Lave & Wenger, 1991 ) and evidence that peer modelling enhances clinical reasoning and engagement (Soosay Raj et al., 2025 ; Collett et al., 2022 ; Dennick, 2016 ). Furthermore, participants recognised the role of interprofessional contributions, particularly from clinical pharmacists, as a vital source of supplementary teaching. This exposure, which contributed to a more holistic understanding of patient care, is a theme seldom emphasised in earlier ward-round research and aligns with modern competency frameworks advocating for team-based learning (Hosny et al., 2025 ; Frank, Snell and Sherbino, 2015 ). Finally, learners viewed structured assessment tools such as the Mini-CEX and Chart-Stimulated Recall as valuable teaching aids. This finding is consistent with literature highlighting their dual function as both formative assessment and real-time teaching opportunities (Norcini, 2003; Schipper and Ross, 2010 ). Formative workplace-based assessment tools, such as the Mini-Clinical Evaluation Exercise (Mini-CEX), have been shown to support feedback and reflective learning when embedded within routine clinical practice (Martinsen et al., 2021 ). Barriers to Learning Despite overall positive perceptions, several barriers limited the educational effectiveness of ward rounds. The most frequent challenges were workload intensity, large patient lists, post-call exhaustion, and competing service demands. Residents often described rounds focused mainly on completing administrative tasks and finishing the list, rather than exploring the reasoning behind management decisions. This reflects global concerns that clinical service pressures can overshadow education in busy hospital settings (Noorani, 2022 ; Khalaf & Khan, 2022 ). Participants noted that both the number and the complexity of cases shaped the workload. Managing patients who required multiple speciality consultations or extensive social coordination left little time for teaching, a finding similar to those of Beigzadeh et al. ( 2019 ) and Wazir & Pandita ( 2025 ). Participants also highlighted the impact of rapid patient turnover, often related to bed pressures and inter-ward transfers, which reduced continuity and limited opportunities to follow up on management outcomes. Continuity is known to support experiential learning by allowing trainees to observe the consequences of their clinical decisions and refine their judgment over time (Billett, 2016 ). The geographical dispersion of patients across multiple wards, a contextual feature of the study setting, fragmented the rounding process, leading to physical fatigue and reduced teaching efficiency (Al Halabi et al., 2023 ). Another finding, not widely reported in previous research, was the influence of social and family-related discussions on the timing and rhythm of ward rounds. In this cultural context, strong family involvement in care decisions often extended rounds and reduced opportunities for teaching and reflection. While these conversations are essential for patient-centred care, they can also create tension between clinical and educational priorities. This finding aligns with socio-cultural perspectives that view workplace learning as embedded within wider social relations and institutional structures (Alkhaibari et al., 2023 ; Jazieh et al., 2018 ). However, the specific influence of family and cultural expectations on educational flow appears underexplored, representing a novel contribution of this study. Additional context-specific and under-reported organisational barriers were also reported. Overflow admissions of non-medical patients, such as those requiring thoracic surgery, are a logistical challenge not typically highlighted as a primary educational barrier in the literature, drawing attention away from core internal medicine learning. This situation occurs in institutions where certain specialities do not have admitting privileges, leaving their patients under the care of general medicine teams. Frequent interruptions, such as non-urgent calls and task requests, are a common yet seldom studied disruptor of educational flow. They disrupt teaching and break the rhythm of rounds, further limiting residents’ engagement, particularly when combined with clinical workload. For students, the fast pace sometimes limited sense-making, consistent with Choi et al.'s (2024) observations that speed and hierarchy can constrain learners’ participation in clinical reasoning during rounds. Taken together, these findings show that the barriers to ward-round learning are systemic, involving workload, case complexity, physical layout, cultural expectations, and institutional responsibilities, rather than isolated teaching deficiencies. Feedback and Reflection A recurrent subtheme across all groups was the limited availability of meaningful feedback and reflection opportunities, which participants viewed as central to the educational value of ward rounds. Feedback was frequently described as delayed and summative, delivered through online evaluation systems rather than in real time at the bedside. This finding echoes long-standing evidence that feedback remains the “most underused learning opportunity” in ward rounds (Gonzalo et al., 2014 ; Ratelle et al., 2022 ). In contrast, the learners in our study valued brief, on-the-spot comments during case discussions or immediately after presentations, as well as feedback that clarified expectations, reinforced reasoning, and fostered reflective practice. Recent frameworks, such as the BEDSIDE2-R model (Nelson et al., 2025 ) and feed-forward reflection approaches (Archer, 2010 ) that focus on future-oriented guidance, advocate embedding micro-feedback moments within rounds to promote reflection-in-action (Schön, 1983 ). The participants’ preference for immediate, dialogic feedback rather than delayed written appraisal aligns closely with these principles. Integrating structured reflection cycles, where learners articulate key learning points or identify improvement goals, could further consolidate reasoning and self-regulation. While residents appreciated informal peer feedback from senior colleagues, they sought greater consultant engagement in formative critique. Similar findings were reported by Wazir and Pandita ( 2025 ), who observed that trainees value feedback linking procedural correctness with professional judgement, thereby supporting the development of clinical identity. Strategies and Suggestions for Improvement Participants proposed pragmatic, context-sensitive strategies spanning workload management, operational efficiency, and faculty development to enhance the educational yield of ward rounds, many of which echoed evidence-based reforms described in recent literature. Capping patient numbers: Limiting daily caseloads (suggested range: 6–8 patients per resident) was considered essential to sustaining teaching quality. Similar recommendations have been reported by Beigzadeh et al. ( 2019 ), who found that smaller lists enable more consistent reasoning, discussion, and feedback. Geographical localisation: Concentrating team patients within fewer wards was a recurring recommendation to reduce transit time and preserve focus. This aligns with time-motion research conducted in the same institution, which demonstrated that dispersed patient allocation substantially increases non-teaching time during rounds (Al Halabi et al., 2023 ). Pre-round huddles and sitting rounds: Brief preparatory meetings to clarify objectives and roles before bedside visits, as reported by several participants, parallel the STIC (Seek–Target–Inspect–Closure) framework described by Collett et al. ( 2022 ), which promotes structure, shared goals, and efficiency in ward-based learning without constraining spontaneity. Faculty development and standardisation: Participants called for systematic development of consultants in bedside teaching and feedback methods to address variability observed across teams. Evidence indicates that faculty development programmes enhance learner satisfaction and increase opportunities for clinical reasoning (Noorani, 2022 ). Registrar-only reflection sessions: Senior residents proposed protected forums to discuss complex management reasoning beyond service rounds. This peer-level debriefing complements work-based learning theory by creating a community of practice for reflective dialogue (Wenger, 1998 ). Synthesis and Theoretical Integration The findings of this study highlight ward-round learning as a process shaped by participation, interaction, feedback, and reflection within everyday clinical practice. Learning did not occur simply through exposure to clinical activity, but through how learners were invited to engage, reason, and contribute during patient care. The educational value of ward rounds was therefore closely linked to social dynamics, supervisory practices, and opportunities for dialogue rather than to structure alone. Viewed through experiential and socio-cultural perspectives, the ward round emerges as a learning space in which meaning is constructed through active involvement in real clinical work. Learners progressed when they were supported to observe, articulate reasoning, test ideas, and reflect on decisions in context. Conversely, when service pressures or hierarchical norms limited participation, learning opportunities were reduced. These findings echo established models of experiential learning and situated practice while illustrating how the realities of a high-acuity clinical environment shape these processes. Importantly, this study demonstrates how contextual factors—such as patient dispersion, workload intensity, and family involvement in care discussions—mediate learning interactions on ward rounds. Rather than being peripheral, these factors shaped the rhythm, focus, and depth of educational engagement. In this respect, the findings align with socio-cultural accounts of workplace learning that emphasise the interdependence of educational activity, institutional structures, and broader social expectations. Together, these insights suggest that optimising ward-round learning requires attention not only to teaching techniques, but also to the conditions that enable meaningful participation and reflection during routine care. Ward rounds function most effectively as learning spaces when clinical teachers intentionally balance service demands with opportunities for dialogue, reasoning, and feedback, allowing learners at different stages to engage in ways that support both clinical competence and professional identity formation. Strengths and Limitations A key strength of this study lies in its triangulation across learner levels and its reflexive methodological design, which intentionally mitigated hierarchical influence. The use of resident moderators enhanced authenticity and candour, while multi-level analysis captured developmental differences across the continuum of training. The study adds novel contextual insights by highlighting how cultural expectations, family dynamics and geographical dispersion shape learning during ward rounds in a large Middle Eastern tertiary hospital. These dimensions are seldom addressed in the international literature, thereby contributing to a broader understanding of ward-round learning in complex institutional systems. The single-institution scope limits generalisability; however, thematic saturation and alignment with recent international research support analytic transferability. Future multi-centre studies across Gulf Cooperation Council hospitals could explore how institutional culture and organisational structures influence the balance between clinical service and education, and evaluate faculty development interventions informed by these findings. Implications for Practice and Policy The findings highlight three domains for practical implementation: Faculty development: Train consultants in structured questioning, modelling clinical reasoning, and providing concise, real-time feedback during rounds. Operational reform: Cap patient lists, cluster geographically dispersed wards, and reduce overflow admissions to safeguard educational time and continuity of care. Learner empowerment: Encourage pre-round goal setting, peer-learning activities, and registrar-level reflective sessions to promote active engagement. Embedding these measures within consultant development initiatives and local institutional processes could help transform ward rounds from variable experiences into more consistently high-yield learning opportunities. Future Recommendations Building on these findings, future work should evaluate the impact of structured faculty development programmes designed to enhance bedside teaching and feedback during ward rounds. Multi-centre studies across Gulf Cooperation Council hospitals could identify institutional and cultural variations influencing the educational climate. Embedding learner feedback mechanisms and measuring patient-related outcomes would further clarify how educational optimisation aligns with clinical quality and safety. Conclusion Ward rounds remain an indispensable setting for experiential learning in internal medicine. Learners valued them for providing authentic exposure to reasoning, teamwork and patient care; however, service pressures, inconsistent supervision and limited feedback constrained their potential. By reframing ward rounds as deliberately designed learning environments supported by consultant training, protected time and reflection, institutions can balance service efficiency with educational purpose, realising the view of learning as a collaborative process that transforms both individuals and professional practice. Practice Points Ward rounds are powerful but inconsistently optimised learning environments; their educational value depends heavily on consultant behaviour, team dynamics, and contextual pressures. Structured faculty engagement—including explicit reasoning, purposeful questioning, and brief real-time feedback—significantly enhances learning across all trainee levels. Service pressures, post-call workload, and geographical dispersion of patients are key systemic barriers that reduce teaching time and trainee engagement. Peer and cross-level learning, interprofessional input, and structured assessment tools (e.g., Mini-CEX, CSR) act as strong enablers of learning when intentionally integrated into rounds. Operational strategies such as capping patient lists, localising patient locations, and conducting brief pre-round huddles can improve efficiency and create more protected educational opportunities. Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the relevant institutional research ethics committee prior to data collection. The study was conducted in accordance with the principles of the Declaration of Helsinki. All participants received written information about the study and provided informed consent before participation. Participation was voluntary, and confidentiality and anonymity were maintained throughout the research process . Consent for publication Not applicable. No individual-level identifying data are included in this manuscript. Availability of data and materials The datasets generated and analysed during the current study are not publicly available due to the qualitative nature of the data and the need to protect participant confidentiality. However, they are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors’ contributions AH conceived the study, led the study design, obtained ethical approvals, coordinated the conduct of the research, supervised data collection, conducted the qualitative analysis, and drafted the manuscript. AE provided local academic and clinical oversight, supported study governance and implementation within the department, and critically reviewed the manuscript. RAK provided academic supervision throughout the project, contributed to study conceptualisation and methodological rigour, supported interpretation of the findings, and critically revised the manuscript for important intellectual content. RA, AHd, MAH, EM, and RTM jointly facilitated and conducted the focus group discussions, contributed to transcription and data preparation, and supported preliminary interpretation of the findings. 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Focus groups: a practical guide for applied research. 5th ed. Thousand Oaks, CA: Sage; 2015. Laskaratos FM, Wallace D, Gkotsi D, Burns A, Epstein O, Gallacher P. The educational value of ward rounds for junior trainees. Med Educ Online. 2015;20(1):27559. https://doi.org/10.3402/meo.v20.27559 . Lave J, Wenger E. Situated learning: Legitimate peripheral participation. Cambridge: Cambridge University Press; 1991. Lincoln YS, Guba EG. Naturalistic Inquiry. Beverly Hills, CA: Sage; 1985. Marshall MN. Sampling for qualitative research. Fam Pract. 1996;13(6):522–6. https://doi.org/10.1093/fampra/13.6.522 . Martinsen SSS, Espeland T, Berg EAR, Samstad E, Lillebo B, Slørdahl TS. 2021. Examining the educational impact of the mini-CEX: a randomised controlled study. BMC Medical Education, 21(1), p.228. Nelson RE, Kanjee Z, Freed J, Cichon CJ, Ricotta DN. BEDSIDE2-R: A framework for team‐based, patient-centred bedside rounds. J Hosp Med. 2025;20(2):200–4. Noorani M. The ward round: friend or foe in postgraduate training? Med Educ Online. 2022;27(1):2101180. https://doi.org/10.1080/10872981.2022.2101180 . Norcini JJ, Blank LL, Duffy FD, Fortna GS. The mini-CEX: a method for assessing clinical skills. Ann Intern Med. 2003;138(6):476–81. Nowell LS, Norris JM, White DE, Moules NJ. Thematic analysis: striving to meet the trustworthiness criteria. Int J Qualitative Methods. 2017;16(1):1–13. https://doi.org/10.1177/1609406917733847 . Patton MQ. Qualitative Research & Evaluation Methods: Integrating Theory and Practice. 4th ed. Thousand Oaks, CA: Sage; 2015. Ratelle JT, Gallagher CN, Sawatsky AP, Kashiwagi DT, Schouten WM, Gonzalo JD, Beckman TJ, West CP. The effect of bedside rounds on learning outcomes in medical education: a systematic review. Acad Med. 2022;97(6):923–30. Ritchie J, Lewis J, Nicholls CM, Ormston R. Qualitative research practice: a guide for social science students and researchers. 2nd ed. London: Sage; 2014. Saldana J. The coding manual for qualitative researchers. 4th ed. London: Sage; 2021. Schipper S, Ross S. Structured teaching and assessment: a new chart-stimulated recall worksheet for family medicine residents. Can Fam Physician. 2010;56(9):958–9. Schön DA. The Reflective Practitioner: How Professionals Think in Action. New York: Basic Books; 1983. Soosay Raj TA, Omer N, Gray AZ. The Use of a Ward Round Teaching Tool in a Paediatric Oncology Department. Journal of Paediatrics and Child Health; 2025. Taha MH, Abdalla ME, Wadi M, Khalafalla H. 2020. Curriculum delivery in Medical Education during an emergency: A guide based on the responses to the COVID-19 pandemic. MedEdPublish, 9, p.69. Tariq M, Motiwala A, Ali SU, Riaz M, Awan S, Akhter J. The learners’ perspective on internal medicine ward rounds: a cross-sectional study. BMC Med Educ. 2010;10(1):53. https://doi.org/10.1186/1472-6920-10-53 . Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57. Vick S, Ragsdale J. Preparing interns as teachers: teaching fourth-year medical students the tenets of the One-Minute Preceptor model. Volume 19. MedEdPORTAL; 2023. p. 11371. Vygotsky LS. Mind in society: the development of higher psychological processes. Cambridge, MA: Harvard University Press; 1978. Wazir A, Pandita S. 2025. Opening the Curtains on Medical Students' Engagement With Ward Rounds: A Qualitative Study. Cureus, 17(9). Wenger E. Communities of Practice: learning, meaning and identity. Cambridge: Cambridge University Press; 1998. Yardley S, Teunissen PW, Dornan T. Experiential learning: transforming theory into practice. Med Teach. 2012;34(2):161–4. Yin RK. Case study research and applications: design and methods. 6th ed. Thousand Oaks, CA: Sage; 2018. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8502082","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":586402966,"identity":"cf4ba4eb-51d3-4f6c-932b-f644cce4f14d","order_by":0,"name":"Abdelrahman 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As routine yet high-stakes activities, ward rounds represent a key interface between service delivery and education, where moment-to-moment interactions, clinical priorities, and supervisory practices shape learning. Early work on bedside ward rounds highlighted their role in fostering experiential learning and clinical engagement across training levels (Gonzalo et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2009\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhen effectively facilitated, ward rounds allow learners to integrate theoretical knowledge with clinical practice through observation, participation, and reflection, supporting the development of clinical competence and professional identity (Yardley et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Cruess et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). However, their educational value is highly variable. Prior studies have shown that competing service pressures, time constraints, and differences in consultant teaching styles can limit learner engagement and reduce opportunities for meaningful participation (Claridge, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Gonzalo et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Noorani, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Studies examining learners’ perspectives consistently report that, while ward rounds are perceived as educationally valuable, their learning potential is frequently constrained by efficiency-driven practices (Tariq et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Eljack et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eImportantly, learners at different stages of training may experience ward rounds differently. Undergraduate medical students often occupy observational or peripheral roles, whereas residents are expected to participate actively in clinical decision-making and patient management. How ward rounds accommodate these differing learning needs and how clinical teachers navigate this complexity in practice remain underexplored. Much of the existing literature examines medical students or residents in isolation, with limited attention to how both groups experience the same ward round environment simultaneously.\u003c/p\u003e \u003cp\u003eWhile these challenges have been described across diverse healthcare systems, contextual factors may further shape ward-round learning. In Middle Eastern teaching hospitals, for example, hierarchical clinical structures, strong family involvement in care discussions, and multicultural clinical teams may influence participation, communication, and teaching dynamics (Helmich et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Jazieh et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Taha et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Understanding how such factors interact with routine ward-round practices can offer relevant insights not only locally but also to other high-volume teaching environments facing similar pressures.\u003c/p\u003e \u003cp\u003eThis study explores how final-year medical students and internal medicine residents perceive the educational value of ward rounds within a large tertiary teaching hospital. By comparing learner experiences across training levels, the study aims to identify factors that enable or constrain learning during ward rounds and to generate practical insights to support clinical teachers in maximising educational opportunities during routine patient care.\u003c/p\u003e\n\u003ch3\u003eResearch Aim and Objectives\u003c/h3\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eTo explore how undergraduate medical students and postgraduate internal medicine residents perceive the educational value of ward rounds and to identify opportunities to enhance learning during routine clinical practice.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eObjectives\u003c/h3\u003e\n\u003cp\u003eTo explore learners’ experiences and perceptions of ward rounds as educational activities.\u003c/p\u003e \u003cp\u003eTo identify barriers and enablers influencing learning during ward rounds.\u003c/p\u003e \u003cp\u003eTo develop participant-informed recommendations to enhance ward-round teaching for learners at different stages of training.\u003c/p\u003e\n\n\n\n \n\n \n\n "},{"header":"Project Design and Methods","content":"\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis study employed a qualitative, exploratory design, suitable for investigating underexplored phenomena in which participants’ experiences are central (Creswell \u0026amp; Poth, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Ritchie et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Yin, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). It explored how medical trainees perceived and constructed meaning from ward-round experiences in a teaching hospital setting.\u003c/p\u003e\u003cp\u003eA constructivist paradigm informed the design, viewing knowledge as co-constructed through interaction and reflection (Vygotsky, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e1978\u003c/span\u003e; Dennick, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). This orientation supported the aim of understanding how learners at different training stages interpreted ward-round learning. Reporting follows the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist (Tong et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2007\u003c/span\u003e).\u003c/p\u003e\u003ch3\u003eSetting\u003c/h3\u003e\u003cp\u003eThe study was conducted at Hamad General Hospital (HGH), a 600-bed tertiary teaching hospital within Hamad Medical Corporation (HMC) in Doha, Qatar. HGH is the leading internal medicine training site in the country. It hosts the core clinical rotations for undergraduate medical students from Qatar University College of Medicine and residents of the national Internal Medicine Residency Programme.\u003c/p\u003e\u003cp\u003eA single-centre design enabled in-depth contextual analysis and control of institutional variables, ensuring consistent structures and culture for cross-level comparisons (Marshall, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e1996\u003c/span\u003e; Creswell and Poth, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\u003ch2\u003eParticipant Recruitment and Sampling\u003c/h2\u003e\u003cp\u003e Participants included final-year medical students from the Qatar University College of Medicine and internal medicine residents (PGY1–PGY4) enrolled in the Hamad Medical Corporation (HMC) Internal Medicine Residency Programme. Eligible trainees who had recently completed their inpatient internal medicine rotations at Hamad General Hospital were contacted via their respective programme offices shortly after rotation completion.\u003c/p\u003e\u003cp\u003eThis approach approximated total-population sampling by purposively varying across training levels, consistent with qualitative sampling strategies that aim for maximum variation and contextual depth (Patton, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Recruitment occurred within two weeks of rotation completion to maximise recall.\u003c/p\u003e\u003cp\u003eFocus groups were organised primarily by training level: three junior-only (PGY1–2), three senior-only (PGY3–4), and three student-only groups, to reduce hierarchical influence and encourage level-specific discussion. Additionally, two mixed groups comprising both junior and senior residents were conducted. Initially, they were for scheduling feasibility, but they proved valuable for capturing cross-level interactions and comparative perspectives.\u003c/p\u003e\u003cp\u003eResident groups consisted of 4–6 participants, and student groups consisted of 4 participants each. We continued recruitment until robust representation was achieved from each participant group. Thematic saturation was confirmed after the ninth focus group, as the final two discussions (one with senior residents and one with students) yielded no new codes or concepts, only repetition and refinement of existing ideas. Recruitment was therefore concluded at this stage.\u003c/p\u003e\u003ch3\u003eData Collection\u003c/h3\u003e\u003cp\u003eFocus group discussions (FGDs) were the sole data-collection method, chosen for their ability to elicit interactive dialogue and reveal both shared and divergent perceptions (Kitzinger, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e1995\u003c/span\u003e; Krueger \u0026amp; Casey, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Each 45–60-minute session was conducted face-to-face during protected departmental time in September 2025 and was recorded via Microsoft Teams.\u003c/p\u003e\u003cp\u003eA semi-structured guide (Appendix 1) was developed, drawing on experiential and constructivist learning theories (Kolb, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e1984\u003c/span\u003e; Vygotsky, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e1978\u003c/span\u003e; Dennick, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), to explore learners’ experiences, perceived educational value, enablers and barriers, and suggestions for improvement.\u003c/p\u003e\u003cp\u003eTo minimise faculty–trainee power dynamics, the FGDs were conducted by trained resident facilitators: two junior residents (PGY1) and two final-year medical students, who had no supervisory or evaluative role over participants and who piloted the guide with the principal investigator (PI) to ensure consistent questioning.\u003c/p\u003e\u003cp\u003e The PI observed sessions remotely and passively via Microsoft Teams to ensure methodological consistency across facilitators and reviewed early transcripts to confirm appropriate alignment with the study aims. No field notes were taken; the analysis relied on verbatim transcripts and audio recordings. Ethical approval was obtained from the HMC Medical Research Centre (MRC-01-25-670) and the University of Warwick’s Biomedical and Scientific Research Ethics Committee (REGO-WMS-ME-25.035).\u003c/p\u003e\u003ch3\u003eData Management and Anonymisation\u003c/h3\u003e\u003cp\u003eAll FGDs were recorded on the hospital’s secure Microsoft Teams account, with a temporary audio backup deleted after verification.\u003c/p\u003e\u003cp\u003eRecordings were transcribed verbatim using a secure speech-to-text service. The PI verified transcripts for accuracy, and an independent second coder reviewed a subset to enhance reliability. Personal identifiers were removed and replaced with participant codes (e.g., J1, S2, F3). Contextual details that could enable re-identification were generalised or omitted to maintain confidentiality. Anonymised data were stored on encrypted institutional servers. They will be retained for ten years in accordance with HMC and University of Warwick policies, after which they will be permanently deleted.\u003c/p\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eThematic analysis followed Braun and Clarke’s (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) six-step framework. The process began with familiarisation, during which the PI read and re-read all transcripts to achieve deep immersion. Initial coding was conducted using NVivo software, supplemented by manual line-by-line coding of selected transcripts to ensure inductive codes remained grounded in the raw data. This hybrid approach enhanced analytical depth and trustworthiness (Saldaña, 2021; Nowell et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). An independent coder double coded a subset of transcripts, and any discrepancies were resolved through discussion and iterative refinement of the codebook.\u003c/p\u003e\u003cp\u003eDuring theme development, codes were collated into candidate themes, which were then reviewed and refined against the coded extracts and the complete dataset to ensure coherence and accurate representation. This iterative process included creating thematic maps and reflective discussions to confirm interpretive consistency. In the defining and naming phase, the essence of each theme was articulated and assigned a concise, descriptive title. Finally, report writing involved selecting vivid, representative quotations to weave the analytical narrative presented in this paper.\u003c/p\u003e\u003ch2\u003eTrustworthiness and Reflexivity\u003c/h2\u003e\u003cp\u003eThe trustworthiness of the analysis was ensured by addressing Lincoln and Guba’s (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e1985\u003c/span\u003e) criteria. Credibility was established through data source triangulation—collecting perspectives from students, junior, and senior residents—and through peer debriefing during the analytic process. Dependability and confirmability were supported by maintaining an audit trail of analytical decisions and by double-coding a subset of transcripts, with consensus discussions to refine the codebook. Transferability was enabled through the thick, contextual description of the setting and participants. Reflexivity was maintained through ongoing team discussions regarding preconceptions. To further mitigate the potential influence of the PI's educator-researcher role on participant candour, the PI did not facilitate focus groups and observed sessions remotely to minimise power dynamics.\u003c/p\u003e\u003ch2\u003eEthical Considerations\u003c/h2\u003e\u003cp\u003eThe study posed minimal risk. The Institutional Review Board granted ethical approvals at the study site (Protocol ID: MRC-01-25-670) and the University of Warwick BSREC (REGO-WMS-ME-25.035). Participation was voluntary and confidential, with no impact on academic evaluation. After receiving the Participant Information Leaflet (PIL), participants provided written consent. Before each session, facilitators verbally confirmed the recording and the PI's remote, non-participatory observation, assuring participants that the PI could not identify individuals, which encouraged open dialogue. Participants could withdraw by contacting the PI via institutional email until data anonymisation. The PIL included details on well-being services.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 54 participants took part: 42 residents (24 juniors and 18 seniors, representing 58% of those invited) and 12 final-year students (67% of those invited). Eleven focus groups were conducted: eight with residents (three junior-only, three senior-only, and two mixed) and three with students. Each resident group comprised 4\u0026ndash;6 participants, while each student group comprised 4 participants.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarises participant demographics and focus-group composition for the three learner groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eParticipant Characteristics and focus-group composition.\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInvited\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipated\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTypical group size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFGD composition\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJunior residents (PGY1\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3 junior-only FGDs\u0026thinsp;+\u0026thinsp;2 mixed FGDs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior residents (PGY3\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3 senior-only FGDs\u0026thinsp;+\u0026thinsp;2 mixed FGDs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal-year students\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3 student-only FGDs (same-level)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOverall, participants described ward rounds as a generally positive and valuable learning experience. While some raised mixed or negative aspects, the majority emphasised their central role in clinical education, particularly in bridging theory and practice.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Perceived Educational Value of Ward Rounds\u003c/h2\u003e \u003cp\u003eWard rounds were consistently viewed as a core site of experiential learning, integrating theoretical knowledge with patient care. Students described rounds as their first authentic exposure to clinical reasoning: \u0026ldquo;It gives the clinical sense, books will not\u0026rdquo; (F1). Another noted, \u0026ldquo;Sometimes we just observe, but even listening to the team discussion helps us understand the reasoning process\u0026rdquo; (F2).\u003c/p\u003e \u003cp\u003eJuniors highlighted the value of structured presentations and opportunities to suggest management plans: \u0026ldquo;Presenting in SOAP format and suggesting plans helped me think more broadly\u0026rdquo; (J10). Seniors described a dual role of supervision and decision-making, with learning strongly shaped by consultant style: \u0026ldquo;Some consultants engage us in decisions; others just want to move fast\u0026rdquo; (S2).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: Enablers of Learning\u003c/h2\u003e \u003cp\u003eConsultant behaviour emerged as the most potent enabler of learning. Participants highlighted the value of being actively involved in assessment and management planning, as well as being asked stimulating questions that modelled expert reasoning: \u0026ldquo;When they ask challenging questions, it opens discussion and makes us think\u0026rdquo; (J4).\u003c/p\u003e \u003cp\u003ePeer and cross-level learning further enriched the experience. Juniors relied on seniors for immediate feedback, as one noted: \u0026ldquo;My registrar corrected my notes, that feedback I could use right away\u0026rdquo; (J6). Seniors, in turn, appreciated input from other professionals, with one stating that \u0026ldquo;Every team member adds something, pharmacists and fellows teach practical points\u0026rdquo; (S3). For students, explanations from residents were vital for connecting theory to practice. Structured assessment tools like the Mini-CEX, though primarily designed for evaluation, were often perceived as valuable teaching aids when used consistently, even though their application varied. Creative teaching strategies were also described. One student recounted how a fellow arranged a deliberate bedside teaching exercise: \u0026ldquo;he took us in and taught us the findings in an OSCE-style format\u0026rdquo; (F4).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Barriers to Learning\u003c/h2\u003e \u003cp\u003eDespite a generally positive perception, several systemic barriers hindered learning. Workload was the most prominent. Participants described rounds involving lists of more than 20\u0026ndash;25 patients as overwhelming, forcing them to prioritise service delivery over education: \u0026ldquo;Managing a list of more than twenty patients turns the round into pure service, there is no time left for teaching\u0026rdquo; (J2). The geographical dispersion of patients across wards further reduced time for bedside learning: \u0026ldquo;In the Acute Medical Assessment Unit (AMAU), it is smoother, but across dispersed wards we lose time and focus\u0026rdquo; (S5).\u003c/p\u003e \u003cp\u003eRapid turnover also restricted continuity and follow-up: \u0026ldquo;We could not see outcomes, patients were transferred before we learned from them\u0026rdquo; (S6). Non-medical overflow cases, such as surgical admissions, provided limited internal-medicine learning value: \u0026ldquo;We did nothing for those patients; it felt like wasted time\u0026rdquo; (J3).\u003c/p\u003e \u003cp\u003eSocial and family issues were described as culturally significant yet emotionally taxing. Residents noted that lengthy family discussions about discharge or care decisions often consumed time, drained energy, and caused mental fatigue: \u0026ldquo;By the end of those talks, you lose focus for the next patients\u0026rdquo; (S4).\u003c/p\u003e \u003cp\u003eStudents also reported difficulty keeping up with the pace of rounds: \u0026ldquo;Sometimes rounds moved too fast; we could not follow the reasoning or ask questions\u0026rdquo; (F4). Service pressure on post-call days further reduced learning opportunities: \u0026ldquo;After 24 admissions, you just focus on discharges, not learning\u0026rdquo; (S7).\u003c/p\u003e \u003cp\u003eConsultant variability influenced the educational atmosphere, with some prioritising efficiency over teaching. Frequent interruptions, such as non-urgent calls or task requests, fragmented concentration and disrupted the learning flow: \u0026ldquo;Every few minutes someone calls or asks for orders, it breaks the rhythm and the teaching flow\u0026rdquo; (S8).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eTheme 4: Suggestions for Improvement\u003c/h2\u003e \u003cp\u003eParticipants proposed several practical ways to enhance the educational value of ward rounds. The most common recommendation was to cap patient numbers at 6\u0026ndash;8 per resident or to balance patient loads by complexity, as one respondent suggested: \u0026ldquo;Six to eight per resident would be reasonable\u0026rdquo; (J8).\u003c/p\u003e \u003cp\u003eThey also emphasised geographical localisation of patients and brief pre-round huddles to clarify daily plans: \u0026ldquo;Even five minutes before the round can be high yield\u0026rdquo; (S1). Participants valued structured bedside teaching, even on routine cases\u0026mdash;\u0026ldquo;Better to focus on clinical findings, not basic science\u0026rdquo; (J5)\u0026mdash;and strongly preferred real-time verbal feedback: \u0026ldquo;Verbal feedback on the spot is more useful than the online system\u0026rdquo; (J7).\u003c/p\u003e \u003cp\u003eEngaging residents in management planning was viewed as increasing ownership and learning depth: \u0026ldquo;When we are asked to suggest management plans, it makes us think like doctors, not just note-takers\u0026rdquo; (J10). A need for standardised consultant expectations was clear, with one resident noting, \"Every consultant has a different style; there should be basic consistency\" (J9), a sentiment echoed by a student who found it \"confusing when expectations keep changing\" (F6). Senior residents also proposed dedicated \"registrar-only sessions\" to discuss complex cases in more depth (S8).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarises the main themes and subthemes identified from the analysis, with illustrative participant quotes that exemplify each theme.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of Main Themes, Subthemes, and Illustrative Quotes.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubtheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIllustrative Quote (Code)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1. Perceived Educational Value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudents as observers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;It gives the clinical sense books will not.\u0026rdquo; (F1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObserving the reasoning process\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Sometimes we just observe, but even listening to the team discussion helps us understand the reasoning process.\u0026rdquo; (F2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJuniors as reporters\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Presenting in SOAP format and suggesting plans helped me think more broadly.\u0026rdquo; (J10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSeniors as decision-makers / supervisors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Some consultants engage us in decisions; others just want to move fast.\u0026rdquo; (S2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2. Enablers of Learning\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsultant engagement (planning, questioning, modelling)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;When they ask challenging questions, it opens discussion and makes us think.\u0026rdquo; (J4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePeer and cross-level learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;My registrar corrected my notes\u0026mdash;that feedback I could use right away.\u0026rdquo; (J6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLearning from wider team (e.g. pharmacists, fellows)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Every team member adds something\u0026mdash;pharmacists and fellows teach practical points.\u0026rdquo; (S3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResident explanations for students\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;When residents explained why certain tests were ordered, it connected theory with practice.\u0026rdquo; (F3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStructured tools (Mini-CEX, CSR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;If all consultants used them, it would really improve us.\u0026rdquo; (S4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCreative strategies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;We were not allowed to see the patient first\u0026hellip; afterwards, he took us in and taught us the findings in an OSCE-style format.\u0026rdquo; (F4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3. Barriers to Learning\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh workload (volume and complexity)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Managing a list of more than twenty patients turns the round into pure service\u0026mdash;there is no time left for teaching.\u0026rdquo; (J2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase complexity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Three complex patients can overwhelm you more than ten simple ones.\u0026rdquo; (J1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeographical dispersion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;In AMAU, it is smoother, but across dispersed wards, we lose time and focus.\u0026rdquo; (S5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRapid turnover (transfers)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;We could not see outcomes; patients were transferred before we learned from them.\u0026rdquo; (S6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-medical overflow cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;We did nothing for those patients; it felt like wasted time.\u0026rdquo; (J3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocial / family issues (emotional burden)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;By the end of those talks, you lose focus for the next patients.\u0026rdquo; (S4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFast pace for students\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Sometimes rounds moved too fast; we could not follow the reasoning or ask questions.\u0026rdquo; (F5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eService pressure (post-call)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;After 24 admissions, you just focus on discharges, not learning.\u0026rdquo; (S7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsultant variability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Some consultants focus on education, others just want to get through quickly.\u0026rdquo; (S8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInterruptions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Every few minutes someone calls or asks for orders\u0026mdash;it breaks the rhythm and the teaching flow.\u0026rdquo; (S9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e4. Suggestions for Improvement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCapping patient numbers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Six to eight per resident would be reasonable.\u0026rdquo; (J8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeographic localisation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;If patients were closer together, we would waste less time.\u0026rdquo; (S1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-round huddles/sitting rounds\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Even five minutes before the round can be high yield.\u0026rdquo; (S1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStructured bedside teaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Better to focus on clinical findings, not basic science.\u0026rdquo; (J5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReal-time feedback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Verbal feedback on the spot is more useful than the online system.\u0026rdquo; (J7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEngage residents in management planning.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;When we are asked to suggest management plans, it makes us think like doctors, not just note-takers.\u0026rdquo; (J10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStandardisation of consultant expectations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Every consultant has a different style; there should be basic consistency.\u0026rdquo; (J9) / \u0026ldquo;It is confusing when expectations keep changing.\u0026rdquo; (F6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRegistrar-only sessions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;Dedicated registrar sessions would let us discuss complex cases in more depth.\u0026rdquo; (S10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAcross all themes, participants recognised ward rounds as a vital but inconsistently realised educational opportunity. Consultant behaviour, service pressures, and contextual constraints strongly shaped the learning experience. Suggested improvements emphasised structure, feedback, and equitable teaching across training levels, highlighting both shared and stage-specific learning needs.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored students' and residents' perceptions of the educational value of internal medicine ward rounds in a large Middle Eastern teaching hospital. The findings align with international studies that emphasise the role of supervisor engagement and structured teaching (Claridge, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Laskaratos et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Gonzalo et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). However, our cross-level comparisons extend this understanding by revealing how the impact of consultant behaviour, service pressures, and unique contextual constraints differs across the training continuum. These findings are crystallised into several key themes, elaborated below.\u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eThe Educational Value and Developmental Trajectory\u003c/h2\u003e \u003cp\u003eAcross learner levels, participants viewed ward rounds as the most genuine and valued learning space, essential for situated learning, clinical reasoning, and bridging theory with practice. This process reflects learning through participation in real clinical activity and legitimate professional practice (Lave \u0026amp; Wenger, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e1991\u003c/span\u003e; Dornan et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor students, rounds served as an initiation into authentic clinical reasoning, learning how doctors think rather than merely what they know. Juniors described gaining fluency in documentation and structured presentation, while seniors emphasised decision-making and leadership. These findings illustrate a scaffolded developmental trajectory\u0026mdash;from observer to reporter to decision-maker\u0026mdash;aligned with Vygotsky\u0026rsquo;s (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e1978\u003c/span\u003e) zone of proximal development. Comparable hierarchies have been identified in grounded-theory studies of postgraduate ward-round learning, where participation progressively shifts from peripheral to central as learners gain confidence and contextual understanding (Noorani, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Wazir \u0026amp; Pandita, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, our cross-level data reveal that this progression is not automatic; it is highly contingent on consultants who actively create \"zones of proximal development\" by calibrating their support to each learner's stage. For students, this means making reasoning explicit; for seniors, it means ceding decision-making authority. This highlights a critical implication: without intentional faculty mediation, the inherent educational structure of the ward round may fail to realise its developmental potential.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eConsultant Influence \u0026amp; Learning Climate\u003c/h2\u003e \u003cp\u003eThe consultant\u0026rsquo;s teaching style was the strongest determinant of educational yield, often outweighing case complexity (Khalaf \u0026amp; Khan, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Noorani, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Supportive consultants who engaged learners through questioning, explanation, and feedback cultivated psychologically safe environments (Edmondson \u0026amp; Lei, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), whereas directive or efficiency-driven styles restricted dialogue.\u003c/p\u003e \u003cp\u003eObservational data indicate that fewer than one-fifth of ward-round interactions involve explicit teaching (Kilian et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), underscoring untapped potential. Our findings confirm that even brief modelling or questioning episodes generated high-impact learning moments. Articulating reasoning or inviting residents to justify plans fostered engagement, while abrupt decision-making promoted passivity.\u003c/p\u003e \u003cp\u003eThis influence underscores the need for structured faculty development. Evidence from targeted faculty development initiatives demonstrates that hospitalist teaching behaviours during routine clinical work can be enhanced through focused interventions without prolonging ward rounds or compromising service efficiency (Caputo et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Interventions such as BEDSIDE2-R, which organises bedside encounters around observation and feedback (Nelson et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), and the One-Minute Preceptor model, which supports rapid formative teaching (Vick \u0026amp; Ragsdale, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), have enhanced teaching frequency without extending round duration. Participants in our study similarly advocated for embedding consistent elements of discussion, reasoning, and formative feedback across teams, rather than leaving them to individual consultant style.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eEnablers of Effective Learning\u003c/h2\u003e \u003cp\u003eBeyond the consultant's paramount role, three key enablers emerged: peer and cross-level interactions, interprofessional contributions, and the strategic use of structured tools.\u003c/p\u003e \u003cp\u003ePeer and cross-level learning were consistent enablers, with juniors benefiting from observing seniors\u0026rsquo; reasoning and students drawing confidence from supportive team dynamics. This collaborative problem-solving aligns with the participatory model of professional education (Lave \u0026amp; Wenger, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e1991\u003c/span\u003e) and evidence that peer modelling enhances clinical reasoning and engagement (Soosay Raj et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Collett et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Dennick, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, participants recognised the role of interprofessional contributions, particularly from clinical pharmacists, as a vital source of supplementary teaching. This exposure, which contributed to a more holistic understanding of patient care, is a theme seldom emphasised in earlier ward-round research and aligns with modern competency frameworks advocating for team-based learning (Hosny et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Frank, Snell and Sherbino, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFinally, learners viewed structured assessment tools such as the Mini-CEX and Chart-Stimulated Recall as valuable teaching aids. This finding is consistent with literature highlighting their dual function as both formative assessment and real-time teaching opportunities (Norcini, 2003; Schipper and Ross, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Formative workplace-based assessment tools, such as the Mini-Clinical Evaluation Exercise (Mini-CEX), have been shown to support feedback and reflective learning when embedded within routine clinical practice (Martinsen et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eBarriers to Learning\u003c/h2\u003e \u003cp\u003eDespite overall positive perceptions, several barriers limited the educational effectiveness of ward rounds.\u003c/p\u003e \u003cp\u003eThe most frequent challenges were workload intensity, large patient lists, post-call exhaustion, and competing service demands. Residents often described rounds focused mainly on completing administrative tasks and finishing the list, rather than exploring the reasoning behind management decisions. This reflects global concerns that clinical service pressures can overshadow education in busy hospital settings (Noorani, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Khalaf \u0026amp; Khan, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Participants noted that both the number and the complexity of cases shaped the workload. Managing patients who required multiple speciality consultations or extensive social coordination left little time for teaching, a finding similar to those of Beigzadeh et al. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) and Wazir \u0026amp; Pandita (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eParticipants also highlighted the impact of rapid patient turnover, often related to bed pressures and inter-ward transfers, which reduced continuity and limited opportunities to follow up on management outcomes. Continuity is known to support experiential learning by allowing trainees to observe the consequences of their clinical decisions and refine their judgment over time (Billett, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe geographical dispersion of patients across multiple wards, a contextual feature of the study setting, fragmented the rounding process, leading to physical fatigue and reduced teaching efficiency (Al Halabi et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother finding, not widely reported in previous research, was the influence of social and family-related discussions on the timing and rhythm of ward rounds. In this cultural context, strong family involvement in care decisions often extended rounds and reduced opportunities for teaching and reflection. While these conversations are essential for patient-centred care, they can also create tension between clinical and educational priorities. This finding aligns with socio-cultural perspectives that view workplace learning as embedded within wider social relations and institutional structures (Alkhaibari et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Jazieh et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). However, the specific influence of family and cultural expectations on educational flow appears underexplored, representing a novel contribution of this study.\u003c/p\u003e \u003cp\u003eAdditional context-specific and under-reported organisational barriers were also reported. Overflow admissions of non-medical patients, such as those requiring thoracic surgery, are a logistical challenge not typically highlighted as a primary educational barrier in the literature, drawing attention away from core internal medicine learning. This situation occurs in institutions where certain specialities do not have admitting privileges, leaving their patients under the care of general medicine teams.\u003c/p\u003e \u003cp\u003eFrequent interruptions, such as non-urgent calls and task requests, are a common yet seldom studied disruptor of educational flow. They disrupt teaching and break the rhythm of rounds, further limiting residents\u0026rsquo; engagement, particularly when combined with clinical workload. For students, the fast pace sometimes limited sense-making, consistent with Choi et al.'s (2024) observations that speed and hierarchy can constrain learners\u0026rsquo; participation in clinical reasoning during rounds.\u003c/p\u003e \u003cp\u003eTaken together, these findings show that the barriers to ward-round learning are systemic, involving workload, case complexity, physical layout, cultural expectations, and institutional responsibilities, rather than isolated teaching deficiencies.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eFeedback and Reflection\u003c/h2\u003e \u003cp\u003eA recurrent subtheme across all groups was the limited availability of meaningful feedback and reflection opportunities, which participants viewed as central to the educational value of ward rounds. Feedback was frequently described as delayed and summative, delivered through online evaluation systems rather than in real time at the bedside. This finding echoes long-standing evidence that feedback remains the \u0026ldquo;most underused learning opportunity\u0026rdquo; in ward rounds (Gonzalo et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Ratelle et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In contrast, the learners in our study valued brief, on-the-spot comments during case discussions or immediately after presentations, as well as feedback that clarified expectations, reinforced reasoning, and fostered reflective practice.\u003c/p\u003e \u003cp\u003eRecent frameworks, such as the BEDSIDE2-R model (Nelson et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) and feed-forward reflection approaches (Archer, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) that focus on future-oriented guidance, advocate embedding micro-feedback moments within rounds to promote reflection-in-action (Sch\u0026ouml;n, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e1983\u003c/span\u003e). The participants\u0026rsquo; preference for immediate, dialogic feedback rather than delayed written appraisal aligns closely with these principles. Integrating structured reflection cycles, where learners articulate key learning points or identify improvement goals, could further consolidate reasoning and self-regulation. While residents appreciated informal peer feedback from senior colleagues, they sought greater consultant engagement in formative critique. Similar findings were reported by Wazir and Pandita (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), who observed that trainees value feedback linking procedural correctness with professional judgement, thereby supporting the development of clinical identity.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eStrategies and Suggestions for Improvement\u003c/h2\u003e \u003cp\u003e Participants proposed pragmatic, context-sensitive strategies spanning workload management, operational efficiency, and faculty development to enhance the educational yield of ward rounds, many of which echoed evidence-based reforms described in recent literature.\u003c/p\u003e \u003cp\u003eCapping patient numbers: Limiting daily caseloads (suggested range: 6\u0026ndash;8 patients per resident) was considered essential to sustaining teaching quality. Similar recommendations have been reported by Beigzadeh et al. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), who found that smaller lists enable more consistent reasoning, discussion, and feedback.\u003c/p\u003e \u003cp\u003eGeographical localisation: Concentrating team patients within fewer wards was a recurring recommendation to reduce transit time and preserve focus. This aligns with time-motion research conducted in the same institution, which demonstrated that dispersed patient allocation substantially increases non-teaching time during rounds (Al Halabi et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePre-round huddles and sitting rounds: Brief preparatory meetings to clarify objectives and roles before bedside visits, as reported by several participants, parallel the STIC (Seek\u0026ndash;Target\u0026ndash;Inspect\u0026ndash;Closure) framework described by Collett et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), which promotes structure, shared goals, and efficiency in ward-based learning without constraining spontaneity.\u003c/p\u003e \u003cp\u003eFaculty development and standardisation: Participants called for systematic development of consultants in bedside teaching and feedback methods to address variability observed across teams. Evidence indicates that faculty development programmes enhance learner satisfaction and increase opportunities for clinical reasoning (Noorani, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegistrar-only reflection sessions: Senior residents proposed protected forums to discuss complex management reasoning beyond service rounds. This peer-level debriefing complements work-based learning theory by creating a community of practice for reflective dialogue (Wenger, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e1998\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eSynthesis and Theoretical Integration\u003c/h2\u003e \u003cp\u003eThe findings of this study highlight ward-round learning as a process shaped by participation, interaction, feedback, and reflection within everyday clinical practice. Learning did not occur simply through exposure to clinical activity, but through how learners were invited to engage, reason, and contribute during patient care. The educational value of ward rounds was therefore closely linked to social dynamics, supervisory practices, and opportunities for dialogue rather than to structure alone.\u003c/p\u003e \u003cp\u003eViewed through experiential and socio-cultural perspectives, the ward round emerges as a learning space in which meaning is constructed through active involvement in real clinical work. Learners progressed when they were supported to observe, articulate reasoning, test ideas, and reflect on decisions in context. Conversely, when service pressures or hierarchical norms limited participation, learning opportunities were reduced. These findings echo established models of experiential learning and situated practice while illustrating how the realities of a high-acuity clinical environment shape these processes.\u003c/p\u003e \u003cp\u003eImportantly, this study demonstrates how contextual factors\u0026mdash;such as patient dispersion, workload intensity, and family involvement in care discussions\u0026mdash;mediate learning interactions on ward rounds. Rather than being peripheral, these factors shaped the rhythm, focus, and depth of educational engagement. In this respect, the findings align with socio-cultural accounts of workplace learning that emphasise the interdependence of educational activity, institutional structures, and broader social expectations.\u003c/p\u003e \u003cp\u003eTogether, these insights suggest that optimising ward-round learning requires attention not only to teaching techniques, but also to the conditions that enable meaningful participation and reflection during routine care. Ward rounds function most effectively as learning spaces when clinical teachers intentionally balance service demands with opportunities for dialogue, reasoning, and feedback, allowing learners at different stages to engage in ways that support both clinical competence and professional identity formation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eA key strength of this study lies in its triangulation across learner levels and its reflexive methodological design, which intentionally mitigated hierarchical influence. The use of resident moderators enhanced authenticity and candour, while multi-level analysis captured developmental differences across the continuum of training.\u003c/p\u003e \u003cp\u003eThe study adds novel contextual insights by highlighting how cultural expectations, family dynamics and geographical dispersion shape learning during ward rounds in a large Middle Eastern tertiary hospital. These dimensions are seldom addressed in the international literature, thereby contributing to a broader understanding of ward-round learning in complex institutional systems.\u003c/p\u003e \u003cp\u003eThe single-institution scope limits generalisability; however, thematic saturation and alignment with recent international research support analytic transferability. Future multi-centre studies across Gulf Cooperation Council hospitals could explore how institutional culture and organisational structures influence the balance between clinical service and education, and evaluate faculty development interventions informed by these findings.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Practice and Policy\u003c/h2\u003e \u003cp\u003eThe findings highlight three domains for practical implementation:\u003c/p\u003e \u003cp\u003eFaculty development: Train consultants in structured questioning, modelling clinical reasoning, and providing concise, real-time feedback during rounds.\u003c/p\u003e \u003cp\u003eOperational reform: Cap patient lists, cluster geographically dispersed wards, and reduce overflow admissions to safeguard educational time and continuity of care.\u003c/p\u003e \u003cp\u003eLearner empowerment: Encourage pre-round goal setting, peer-learning activities, and registrar-level reflective sessions to promote active engagement.\u003c/p\u003e \u003cp\u003eEmbedding these measures within consultant development initiatives and local institutional processes could help transform ward rounds from variable experiences into more consistently high-yield learning opportunities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eFuture Recommendations\u003c/h2\u003e \u003cp\u003eBuilding on these findings, future work should evaluate the impact of structured faculty development programmes designed to enhance bedside teaching and feedback during ward rounds. Multi-centre studies across Gulf Cooperation Council hospitals could identify institutional and cultural variations influencing the educational climate. Embedding learner feedback mechanisms and measuring patient-related outcomes would further clarify how educational optimisation aligns with clinical quality and safety.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWard rounds remain an indispensable setting for experiential learning in internal medicine. Learners valued them for providing authentic exposure to reasoning, teamwork and patient care; however, service pressures, inconsistent supervision and limited feedback constrained their potential. By reframing ward rounds as deliberately designed learning environments supported by consultant training, protected time and reflection, institutions can balance service efficiency with educational purpose, realising the view of learning as a collaborative process that transforms both individuals and professional practice.\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003ePractice Points\u003c/h2\u003e \u003cp\u003eWard rounds are powerful but inconsistently optimised learning environments; their educational value depends heavily on consultant behaviour, team dynamics, and contextual pressures.\u003c/p\u003e \u003cp\u003eStructured faculty engagement\u0026mdash;including explicit reasoning, purposeful questioning, and brief real-time feedback\u0026mdash;significantly enhances learning across all trainee levels.\u003c/p\u003e \u003cp\u003eService pressures, post-call workload, and geographical dispersion of patients are key systemic barriers that reduce teaching time and trainee engagement.\u003c/p\u003e \u003cp\u003ePeer and cross-level learning, interprofessional input, and structured assessment tools (e.g., Mini-CEX, CSR) act as strong enablers of learning when intentionally integrated into rounds.\u003c/p\u003e \u003cp\u003eOperational strategies such as capping patient lists, localising patient locations, and conducting brief pre-round huddles can improve efficiency and create more protected educational opportunities.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the relevant institutional research ethics committee prior to data collection. The study was conducted in accordance with the principles of the Declaration of Helsinki. All participants received written information about the study and provided informed consent before participation. Participation was voluntary, and confidentiality and anonymity were maintained throughout the research process\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. No individual-level identifying data are included in this manuscript.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due to the qualitative nature of the data and the need to protect participant confidentiality. However, they are available from the corresponding author on reasonable request.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAH conceived the study, led the study design, obtained ethical approvals, coordinated the conduct of the research, supervised data collection, conducted the qualitative analysis, and drafted the manuscript.\u003c/p\u003e\n\u003cp\u003eAE provided local academic and clinical oversight, supported study governance and implementation within the department, and critically reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003eRAK provided academic supervision throughout the project, contributed to study conceptualisation and methodological rigour, supported interpretation of the findings, and critically revised the manuscript for important intellectual content.\u003c/p\u003e\n\u003cp\u003eRA, AHd, MAH, EM, and RTM jointly facilitated and conducted the focus group discussions, contributed to transcription and data preparation, and supported preliminary interpretation of the findings.\u003c/p\u003e\n\u003cp\u003eAll authors reviewed and approved the final manuscript.\u003cbr\u003e \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAl Halabi A, Alabdulla A, Al-Khulaifi A, Al-Abbasi A, Abdulla A. 2023. 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Thousand Oaks, CA: Sage; 2018.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ward rounds, clinical teaching, workplace learning, medical students, residents, qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-8502082/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8502082/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eWard rounds remain a central component of clinical education in internal medicine, providing learners with opportunities to observe clinical reasoning, participate in patient care, and develop a professional identity. Despite their importance, the educational value of ward rounds is inconsistently realised, particularly in busy teaching environments where service demands may compete with learning.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis qualitative study explored how final-year medical students and internal medicine residents (PGY1\u0026ndash;4) experience ward rounds as learning activities. Eleven focus group discussions were conducted with students and residents at a large tertiary teaching hospital in the Gulf region. Discussions were audio-recorded, transcribed, anonymised, and thematically analysed using Braun and Clarke\u0026rsquo;s framework.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFour interrelated themes were identified. Ward rounds functioned as powerful learning spaces, allowing learners to integrate theory with practice and progress from observation to clinical participation. Consultant behaviour emerged as the most influential factor shaping the learning environment, with interactive teaching and role modelling enhancing engagement, while task-focused approaches constrained it. Learning was further enriched through peer interaction across training levels and collaboration with allied health professionals. However, service pressures, post-call fatigue, fragmented patient locations, and time-consuming family discussions frequently limited educational continuity.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWard rounds remain a vital but underutilised educational resource. Their effectiveness depends less on structure alone and more on how clinical teachers intentionally engage learners during routine care. Supporting faculty development, fostering inclusive participation across learner levels, and recognising common barriers may help clinical educators maximise learning opportunities on ward rounds.\u003c/p\u003e","manuscriptTitle":"Evaluating the Educational Value of Internal Medicine Ward Rounds: Perspectives of Medical Students and Postgraduate Residents","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-07 02:45:53","doi":"10.21203/rs.3.rs-8502082/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-05T13:45:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"210230064349766048515663741996147001690","date":"2026-02-05T12:08:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-04T12:44:40+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-09T05:34:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-08T07:28:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-08T07:24:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-01-02T15:42:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9277d788-4924-4d0d-bae0-d2ee82a60227","owner":[],"postedDate":"February 7th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-07T02:45:53+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-07 02:45:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8502082","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8502082","identity":"rs-8502082","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}