Course:SOWK551/2021/Enhancing Healthcare Staff Well-Being and Compassionate Care with Schwartz Rounds

Short Summary

This entry explores the evidence-base for a promising intervention to mitigate social worker and healthcare worker burnout and compassion fatigue within healthcare organizations, namely, Schwartz Rounds, and advocates for their inclusion within diverse healthcare settings where social workers and other disciplines work to provide compassionate care for their patients.

April 6, 2023

Introduction

As advocates for patient-centered care, social workers are well-positioned within healthcare teams to lead the adoption and facilitation of Schwartz Rounds in their practice settings. Schwartz Rounds have been demonstrated to be effective in enhancing psychological well-being, reduce stress, and to help foster greater insight and emotional awareness of the personal meanings and connections amongst colleagues and patients, which are all protective factors in providing compassionate, humane care (Cullen, 2016).

History of Schwartz Rounds

Schwartz Rounds were formally developed in the mid 1990s, and are named after Ken Schwartz, a health lawyer who died of advanced lung cancer in 1995. Schwartz wrote an article in the Boston Globe newspaper prior to his death, highlighting the profound healing impact of nursing staff who intentionally took a pause from their frenetic work environments to enact small gestures of genuine care and connection with their patients. Schwartz was a beneficiary of compassionate care from one of the nurses supporting him in the hospital as he awaited surgery. As he wrote about in his article for the Boston Globe, the nurse took the time to build a human connection with him, learning about his two-year-old son, and later holding his hand as he was wheeled into surgery. He noted that “the smallest acts of kindness made the unbearable bearable” and helped him feel calmer and more peaceful throughout his time in hospital (Schwartz, 1995). Inspired by the compassionate care he received, Schwartz then founded the non-profit Schwartz Centre for Compassionate Healthcare shortly before his death, devoted to strengthening the human connection at the heart of health care, and, since 1995, the Centre has collaborated with over 550 organizations across the U.S., the U.K., Australia, New Zealand, Ireland, and Canada, providing educational resources, training facilitators to host Schwartz Rounds in healthcare settings, and has hosted regular conferences to advance compassionate care in health care (Flanagan et al., 2020; The Schwartz Center for Compassionate Healthcare, 2022). The organization claims to have reached over 200,000 health care professionals each year through their work and has contributed to peer reviewed studies examining the benefits of Schwartz Rounds to enhance well-being and reduce healthcare staff burnout (The Schwartz Center for Compassionate Healthcare, 2022).

Overview of Schwartz Rounds

Schwartz Rounds are typically hosted once a month during a lunch hour with food, are multidisciplinary, confidential, and focus on allowing staff to explore their feelings and reflect on how they relate to patients, rather than on addressing clinical issues or solving problems (Cullen, 2016). They typically involve two to four people in the presenter role, preferably from various disciplines, sharing stories about a particular theme for that month, such as “when things go wrong,” “a patient or colleague I’ll never forget,” “my worst day at work,” or “why am I here?” focusing on the emotions felt by the staff and the meaning of the patient-caregiver relationship (Cullen, 2016). Presenters are joined by a trained facilitator, which social workers are well suited to be given their training in therapeutic relationality and group processes. The facilitator supports the panel members and audience in discussing and reflecting on their own reactions to the panelist's stories with a respectful curiosity, inviting audience members to share their own emotional experiences, with the focus being on providing a safe space to explore the emotional impact and meaning of people’s work through listening, exploring, extending, and making connections between stories (Cullen, 2016).

Addressing Burnout and Compassion Fatigue

Burnout and compassion fatigue has been a perennial challenge for the profession of social work, though the issue is not only experienced by social workers (Cullen, 2016). Staff shortages, along with increased complexity in healthcare provision, have resulted in excessive levels of psychological distress for healthcare professionals, which has been compounded by the challenges of the Covid-19 pandemic which required many healthcare teams to shift to digital formats to provide care to patients (Hakkak et al., 2022; Maben et al., 2021). Stress is an antecedent of various distressing psychological states such as loss of ideals and burnout, which can reduce compassion and empathy (Maben et al., 2021). In Canada, approximately 45% of healthcare workers suffer from high degrees of work-related stress compared to 31% of the general workforce (Dhinsa et al., 2021). The 2018 Canadian Medical Association National Physician Health Survey found that 30% of surveyed physicians reported burnout and 26% reported high emotional exhaustion (Dhinsa et al., 2021). Similarly, a survey of over 4,500 Canadian nurses found that 40% reported feelings of burnout (Dhinsa et al., 2021).

In response, researchers have highlighted the importance of fostering compassion resilience within organizations, and the need to place greater emphasis on social and organizational responses to foster resilience through enhanced social support networks at work, participative management styles, and regular organizational psychoeducation sessions, in contrast to only attending to interventions that focus on the individual level of self-care and stress reduction (Stoewen, 2022). Schwartz Rounds are an exemplar form of an organization-level intervention that encourages peer support, appreciation for the emotional impact of care-work, and provides a safe, structured place to foster the sharing of difficult experiences and mitigate isolation within the context of emotionally challenging work environments (Reed et al., 2014; Stoewen, 2022). In what follows, peer reviewed literature will be explored, examining the reported benefits and challenges of Schwartz Rounds, followed by suggestions for future areas for research, and helpful guidelines for applying Schwartz Rounds in social work practice.

Schwartz Rounds and Well-Being

Many studies have found positive benefits with Schwartz Round participant well-being. Lown et al. (2010) found through retrospective surveys of participants who had attended Rounds a statistically significant decrease in perceived stress, as well as a statistically significant improved capacity to cope with the psychosocial demands of care-work. Interestingly, it was also found that the more Rounds one attended, the greater the impact on perceived psychosocial care, enhanced teamwork with colleagues and reduced isolation, along with a greater focus on patient-centered care (Lown et al., 2010). The researchers concluded by highlighting Schwartz Rounds as a simple and effective strategy for providing support to healthcare professionals, and for enhancing relationships amongst team-members and their patients (Lown et al., 2010).

A related study, which made use of a control group, as well as measuring respondent’s baseline psychological distress prior to engaging in Schwartz Rounds, found that attendance at Rounds was correlated with a 19% decrease in psychological distress following the 8-month study duration when compared with their peers who had not attended Rounds (Dawson et al., 2021). Other researchers have also noted that clinically notable improvements in reduced stress scores amongst staff became significant after participants attended approximately seven Schwartz Rounds, thus highlighting that it is not a one-shot intervention, but one that requires sustained and consistent application (Adamson et al., 2018). Given the relatively low-cost in facilitating the Rounds, it was deemed to be an effective intervention to support staff with their well-being and health, which is in turn linked to improved outcomes for patients, particular reduced patient mortality and increased patient safety (Dawson et al., 2021; Maben et al., 2021).

Supportive Factors

An in-depth realist evaluation into Schwartz Rounds by Maben et al. (2021) interviewed 97 key participants, including facilitators, panelists, steering group members, and audience members, and concluded with several key findings. Firstly, they offered nine theoretical mechanisms to account for how, why, and for whom Schwartz Rounds were deemed to be most useful and less useful and concluded with offering a host of both supportive and hindering factors for Schwartz Rounds.  The nine partial theories, or mediating factors, that the team suggested as central in explaining the effectiveness of Rounds included: trust, safety, and containment; group interaction; the provision of a counter-cultural or third space for staff; self-disclosure; story-telling; role modelling vulnerability; contextualising patients and staff; shining a light on hidden stories and roles; and reflection and emotional resonance (Maben et al., 2021).

The key takeaways from this in-depth evaluation were that Schwartz Rounds were viewed as more successful by participants when panellists were seen to be prepared, when panellists maintained fidelity to the Schwartz model, when stories role-modelled vulnerability, shared weaknesses and mistakes, when speakers felt safe to be vulnerable and were encouraged to share their emotions, when problem-solving approaches were absent from the discussion, when there was a flattened hierarchy and increased diversity of panellists, and when people felt listened to without judgment (Jakimowicz & Maben, 2020; Maben et al., 2021). These supportive factors were corroborated by multiple other research studies investigating the underlying contributing factors regarding how and why Schwartz Rounds were effective (Farr & Barker, 2017; Flanagan et al., 2020; Moore & Phillips, 2009). These factors all contributed to participants favourably viewing the Rounds as increasing their own reflection, openness, honesty, acceptance of fallibility, resilience, and compassion for staff and patients. Furthermore, it resulted in participants feeling closer to their team members, as well as increased communication amongst teams, increased generosity towards colleagues, and a healthy sense of closure regarding the experience of distressing client cases (Maben et al., 2021). These positive effects for staff were then linked to increased empathy and compassion for patients and resulted in improved quality of care for patients and their families (Maben et al., 2021). Furthermore, Schwartz Rounds have been found to have had the additional benefit of increasing participants’ understanding of interprofessional practice and clinical imagination, which was also linked to improved patient care outcomes (Adamson et al., 2018).

Hindrances

The most notable hinderances to the effectiveness of Schwartz Rounds were participants expressing they were too busy to attend the Rounds or feeling that the organization did not properly plan in advance to allow them to safely take the time to attend, along with facilitators that were seen to be too controlling of the discussion as opposed to guiding, when facilitators appeared to lack group facilitation expertise, when panellists were not prepared in advance, when there was homogeneity of panellist background (i.e. all doctors), and when panellists focused more on factual clinical stories with reduced focus on resonant emotional experiences (Maben et al., 2021). Nonetheless, even when healthcare staff could not attend the Schwartz Rounds, or in cases where staff consciously elected to not participate in them, those staff often still expressed appreciation for the value the Rounds brought to their team members and the contribution they made to their organization’s culture of fostering staff well-being and shared purpose, thus highlighting the positive perception the Rounds created amongst the organization, irrespective of whether everyone was attending them regularly or not (Reed et al., 2014).

Strengths

One of the key strengths of Schwartz Rounds is their applicability across a wide range of healthcare environments, with teams having successfully implemented them in children’s hospitals, hospices and palliative care units, general surgery wards, acute care wards, mental health facilities, community health centres, university classrooms, and even in correctional facilities (Farr & Barker, 2017; Hughes et al., 2017; Moore & Phillips, 2009). Another key strength of the Schwartz Rounds is in their non-hierarchical nature. They bring together not just clinical and allied healthcare staff, but also, and importantly, non-clinical staff including managers, cleaners, porters, volunteers, office staff, and maintenance workers (Cullen, 2016). In allowing a space for a range of personnel to share their emotional stories in caring for patients, this contributes to participants feeling that they are part of a bigger picture, and can help them better understand how all the pieces of the jigsaw come together to ultimately support patients and staff, which participants in qualitative evaluations of Schwartz Rounds have shared to be a comforting and reassuring element to the Rounds in addition to their educational component (Flanagan et al., 2020; Reed et al., 2014).

Future Research

Regarding participants feeling safe and comfortable sharing their own emotionally vulnerable stories, many noted that they would prefer to share their stories in Rounds that occurred within smaller team environments, where they had already established more trusting relationships with their immediate team members and thus felt freer from negative appraisals or criticism (Allen et al., 2020). Relatedly, participants suggested that having time to process the emotive content of the Rounds before returning to their work would be helpful, as many participants noted they would often conduct Mini Schwartz Rounds with their colleagues upon returning from the larger Rounds, which they found useful to provide more connection and closure to those experiences (Allen et al., 2020). Thus, organizations ought to consider allowing space and time for team members to review the larger Schwartz Round together in smaller groups prior to returning to their work, and further research ought to directly explore the utility of providing extra emotional support in the form of consultation with a clinical professional for self-selected participants following the completion of Rounds. Relatedly, research exploring the differential impacts of Schwartz Rounds depending on their size and frequency should be conducted, to ascertain whether such Rounds could be as effective with smaller teams, and on a more frequent basis, perhaps once a week or bi-weekly. And finally, given the prevalence of digital tools in providing healthcare services, and with some teams requiring less in-person involvement than prior to the Covid-19 pandemic, research should be conducted examining the perceived benefits and differences of virtual Schwartz Rounds, and how these can be best utilized by organizations to enhance the well-being of a workforce that may be working from home and more siloed than previously (Dhinsa et al., 2021).

Application in Social Work Practice

Healthcare organizations typically work with the Schwartz Center to initiate the Rounds. The first steps usually involve identification of a physician leader, a planning committee, and facilitator, who is often a social worker (Moore & Phillips, 2009). Interested social workers can lead the integration and organizational adoption of Schwartz Rounds within their teams and organizations. There are two helpful resources to support social workers in this.

Firstly, The Schwartz Centre for Compassionate Healthcare has an active website containing key resources and information on becoming a member of the Schwartz Rounds program. The Centre has a team of advisors to help organizations gather the necessary knowledge, training, and support to implement and sustain Schwartz Rounds in your practice settings (The Schwartz Center for Compassionate Healthcare, 2022). The Centre requires an annual organizational membership fee, which covers access to trauma-informed training for interested participants to become facilitators of Schwartz Rounds within your organization, along with access to virtual workshops, conferences, consultations, and support in establishing organization-wide, unit-wide, or virtual Schwartz Rounds (The Schwartz Center for Compassionate Healthcare, 2022). Some local hospitals, including BC Children’s, St. Paul’s, and Lions Gate Hospital are already members, so it would be best to reach out for further information and support within those organizations if you find yourself working in one of these sites and are interested in attending or becoming involved in facilitating these Rounds (The Schwartz Center for Compassionate Healthcare, 2023).

Secondly, social workers can consult the free guide developed by researchers at the University of Surrey in the U.K., which outlines key practical and logistical steps needed to successfully implement Schwartz Rounds within your organization, along with creative ideas for novel ways of adapting the Rounds to best suit your team’s needs, size, and preferred mode of interaction (Maben et al., 2018). Some of the key suggestions from the guide are for organizations to provide dedicated funding to train enough facilitators, along with dedicated funding for administrative support and for the provision of food for staff during the Round, and to provide CPD hours and supervision for facilitators and clinical leads (Maben et al., 2018). Relatedly, the guide suggests that organizations should organize a rotation of facilitators to reduce the workload burden, along with a steering group of committed members who dedicate a period of six months at a time to collectively help organize the Rounds, gather panellists, review stories ahead of time, debrief with panellists afterwards, explore with fellow committee members what worked, what could be improved for future Rounds, and support facilitators, panellists, and audience members to maintain and enhance psychological safety during the Rounds (Maben et al., 2018).

References

Adamson, K., Searl, N., Sengsavang, S., Yardley, J., George, M., Rumney, P., Hunter, J., & Myers-Halbig, S. (2018). Caring for the healthcare professional. Journal of Health Organization and Management, 32(3), 402-415. https://doi.org/10.1108/jhom-05-2017-0103

Adamson, K., Sengsavang, S., Myers-Halbig, S., & Searl, N. (2018). Developing a compassionate culture within pediatric rehabilitation: Does the Schwartz Rounds™ support both clinical and nonclinical hospital workers in managing their work experiences? Qualitative Health Research, 28(9), 1406-1420. https://doi.org/10.1177/1049732318768239

Allen, D., Spencer, G., McEwan, K., Catarino, F., Evans, R., Crooks, S., & Gilbert, P. (2020). The Schwartz centre rounds: Supporting mental health workers with the emotional impact of their work. International Journal of Mental Health Nursing, 29(5), 942-952. https://doi.org/10.1111/inm.12729

Cullen, A. (2016). Schwartz rounds®– promoting compassionate care and healthy organisations. Journal of Social Work Practice, 30(2), 219-228. https://doi.org/10.1080/02650533.2016.1168386

Dawson, J., McCarthy, I., Taylor, C., Hildenbrand, K., Leamy, M., Reynolds, E., & Maben, J. (2021). Effectiveness of a group intervention to reduce the psychological distress of healthcare staff: A pre-post quasi-experimental evaluation. BMC Health Services Research, 21(1), 1-9. https://doi.org/10.1186/s12913-021-06413-4

Dhinsa T. J., Dean P. H., & Strahlendorf C. (2021). Addressing social and emotional aspects of providing healthcare using Schwartz Rounds as an example. UBC Medical Journal, 12(2), 22-24.

Farr, M., & Barker, R. (2017). Can staff be supported to deliver compassionate care through implementing Schwartz rounds in community and mental health services? Qualitative Health Research, 27(11), 1652-1663. https://doi.org/10.1177/1049732317702101

Flanagan, E., Chadwick, R., Goodrich, J., Ford, C., & Wickens, R. (2019). Reflection for all healthcare staff: A national evaluation of Schwartz rounds. Journal of Interprofessional Care, 34(1), 140-142. https://doi.org/10.1080/13561820.2019.1636008

Hakkak, F., Pickstone, S., Freshwater, S., Evans, T., & Ball, R. (2022). P-201 introducing Schwartz rounds during a pandemic. BMJ Supportive & Palliative Care, 12, A85. https://doi.org/10.1136/spcare-2022-hunc.215

Hughes, J., Duff, A. J., & Puntis, J. W. (2017). Using Schwartz center rounds to promote compassionate care in a children’s hospital. Archives of Disease in Childhood, 103(1), 11-12. https://doi.org/10.1136/archdischild-2017-313871

Jakimowicz, S., & Maben, J. (2020). “I can’t stop thinking about it”: Schwartz rounds ^® an intervention to support students and higher education staff with emotional, social and ethical experiences at work. Journal of Clinical Nursing, 29(23-24), 4421-4424. https://doi.org/10.1111/jocn.15354

Lown, B. A., & Manning, C. F. (2010). The Schwartz center rounds: Evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, and provider support. Academic Medicine, 85(6), 1073-1081. https://doi.org/10.1097/acm.0b013e3181dbf741

Maben, J., Leamy, M., Taylor, C., Reynolds, E., Shuldham, C., Dawson, J., McCarthy, I., Ross, S., & Bennett, L. (2018). An organisational guide: Understanding, implementing and sustaining Schwartz Rounds. https://www.surrey.ac.uk/sites/default/files/Schwartz-rounds-organisational-guide.pdf

Maben, J., Taylor, C., Reynolds, E., McCarthy, I., & Leamy, M. (2021). Realist evaluation of Schwartz rounds® for enhancing the delivery of compassionate healthcare: Understanding how they work, for whom, and in what contexts. BMC Health Services Research, 21(1), 1-24. https://doi.org/10.1186/s12913-021-06483-4

Moore, C. D., & Phillips, J. M. (2009). In these rounds, health-care professionals heal themselves. Journal of Social Work in End-Of-Life & Palliative Care, 5(3-4), 116-125. https://doi.org/10.1080/15524250903555064

Reed, E., Cullen, A., Gannon, C., Knight, A., & Todd, J. (2014). Use of Schwartz centre rounds in a UK hospice: Findings from a longitudinal evaluation. Journal of Interprofessional Care, 29(4), 365-366. https://doi.org/10.3109/13561820.2014.983594

Schwartz, K. B. (1995, July 16). A patient’s story. https://www.bostonglobe.com/magazine/1995/07/16/patient-story/q8ihHg8LfyinPA25Tg5JRN/story.html

Stoewen D. L. (2022). Moving from compassion fatigue to compassion resilience Part 6: Building organizational resilience. The Canadian veterinary journal = La revue veterinaire canadienne, 63(2), 203–205.

The Schwartz Center for Compassionate Healthcare. (2022, May 13). Healthcare Membership - The Schwartz Center. https://www.theschwartzcenter.org/join/healthcare-membership/

The Schwartz Center for Compassionate Healthcare. (2022, November 16). Schwartz Rounds - The Schwartz Center. https://www.theschwartzcenter.org/programs/schwartz-rounds/

The Schwartz Center for Compassionate Healthcare. (2023, April 6). Schwartz Center Members - The Schwartz Center. https://www.theschwartzcenter.org/about/our-reach/