Monthly ArchiveJune 2015

Kindness suffers as the capacity for fellow feeling recedes – Schwartz Rounds: a revolution in compassionate care

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Dr Rory Conn, Darzi Fellow in quality improvement and patient safety, and ST5 child and adolescent psychiatry, Great Ormond Street Hospital

In 1994, aged just 40, Boston healthcare attorney Ken Schwartz was diagnosed with advanced lung cancer. Over a 10-month ordeal, Ken documented his key reflection: that what matters most during an illness is the human connection between patients and their caregivers. His writings urge healthcare professionals to stay person-centred – it is “the smallest acts of kindness”, he argues, which can make “the unbearable bearable.”

Schwartz recognised that patients are increasingly complex and their care more fragmented. Drives towards greater efficiency and cost savings, alongside greater population disease burden result in relationships between staff members and between staff and patients which are more short-lived; care under these circumstances can become rapidly depersonalised.

Increasingly, we acknowledge that all staff members are affected by the emotional demands of caring for patients, whether they are frontline clinical staff, associated healthcare professionals, or non-clinicians. Rates of work related anxiety and depression are high; recent studies revealing that staff absences for mental health problems have doubled in hospital trusts across England in the past four years alone. The knock-on effects can be startling. Staff “burnout” in the form of emotional exhaustion and depression leads to low work satisfaction and a decreased sense of personal effectiveness, alongside a deterioration in the quality of care.

After his death, the Schwartz Center for Compassionate Healthcare was established. Its mission is simple but compelling: to promote compassionate care so that patients and their caregivers relate to one another in a way that provides “hope to the patient, support to caregivers and sustenance to the healing process”.­­­­­­­

Generally speaking, staff are unaccustomed and unprepared for reflective practice, individually and collectively. We rarely stop to consider how it feels and also what it means, to do the work we do (the stresses and rewards, the ethical dilemmas, the significance of dealing with life and death). How do we find time to recognise and discuss the processes which generate these unique environments?  What narratives do we dare to share with one another, and how?

Crucially, evidence shows that the wellbeing of our patients is highly dependent on the wellbeing of staff. In order for staff to provide compassionate care, staff must themselves feel cared for, by the organisation and each other. Schwartz Rounds address a significant unmet need.

Schwartz rounds are monthly, multidisciplinary meetings of all staff working in a particular healthcare setting. They provide an inclusive, safe, confidential, and boundaried space to reflect on the human dimensions of healthcare.

Provision of food is key: the host organisation must appeal to the most basic of its staff’s needs. The symbolism of a nurturing environment acts powerfully with the anthropological significance of sharing. There is also the analogy of “digesting” something together.

A cross-disciplinary presenting team of three or four staff members talk about a single case, or a series of cases linked by a given theme. Rounds last for an hour, half of which is given over to the panellists’ stories, half to the audience to openly share their thoughts on what they have heard. The analogy I draw is to the Last Night at the Proms. The music played (in this case the stories told by the panel) is essential, but it is the contribution of the audience that gives the event its real meaning. This is an all-teach-all-learn process.

Discussion is chaired by a clinical lead and a facilitator, both of whom have received training from the Point of Care Foundation. The rounds are not problem solving fora, nor group therapy sessions. Attendance is not mandated and the atmosphere should feel non-hierarchial and non-judgemental.

This can be seen as counter-cultural. Staff come together in a way not permitted by the majority of organisational processes, which tend to enhance disengaged, silo working. Schwartz Rounds are as much about celebrating the diversity of clinical approaches and unifying staff in common goals as they are providing a supportive environment.

Ask yourself: how frequently do I consider what other multidisciplinary team members believe about the shared work being done …. what assumptions do I carry about the views of my colleagues as well as my patients, and what drives them to do what they do?

Evidence base

In the US, more than 320 organisations have implemented Schwartz Rounds, whilst the number of hospitals and hospices contracted in the UK has passed 100.  Research shows that attending staff:

  • Feel they communicate better with their patients and colleagues;
  • Feel less isolated and more supported;
  • Feel better able to cope with the emotional pressures of their work; and
  • Understand better how their colleagues think.

Schwartz Rounds are highlighted in the NHS England Business Plan 2014 as an evidence based initiative to improve patient experience and have prominence in the Francis Report as a mechanism for improving team building and cohesiveness.

To find out more, contact The Point of Care Foundation: www.pointofcarefoundation.org.uk

References

1. Ballat J and Campling P (2011) Intelligent Kindness.

Handover: the giving of control or responsibility for something to someone else

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Emma is completing her second year of core surgical training (otolaryngology) in the North West deanery. She is actively involved in a variety of quality improvement projects across the Deanery and has a keen interest in clinical management and leadership.

With increasing shift work, clinical handover can sometimes merely mean the passing over of a bleep rather than the sharing of responsibility. Effective handover is important for patient care as well as benefiting the multi-disciplinary team environment. Despite the clearly recognised importance and impact on continuity of care, it is rarely given appropriate airtime on teaching programmes and ultimately not assessed as a core competence of a clinical practitioner, which could lead to bad habits and loss of emphasis on the process.

In an attempt to counter this, many professional bodies have produced guidelines on written handover documentation – however, such guidelines are often seen to be both time and financially heavy to implement. As a surgical trainee wanting the best for my patients, I spent some time understanding what messages and simple measures can be taken from these guidelines and implemented without the need for large investments in time or money.

This got me wondering, what does handover really mean and what does a good handover look like?

I worked with my colleagues to trial some ideas within my current trust, which serves a population of nearly 900,000 people across four hospital sites. My departmental team consists of six junior doctors providing 24/7 care, resulting in frequent shift changes with challenging handovers.

My ideas were based on guidance from the General Medical Council’s (GMC) Good Medical Practice, (which has a section, Domain 3, dedicated to communication: “Partnership and Teamwork”), advice from the Medical Defence Union[i], and the Royal College of Surgeons of England’s Good Surgical Practice[ii]. The main focus of the guidance is on communication and documentation.

Domain 3 has a subsection titled, “continuity and co-ordination of care”, highlighting that we must contribute to the safe transfer of patients between healthcare and health and social care providers, further specifying the following:

  • Share all relevant information with colleagues involved in your patients’ care within and outside the team, including when you hand over care as you go off duty, and when you delegate care or refer patients to other health or social care providers
  • Check, where practical, that a named clinician or team has taken over responsibility when your role in providing a patient’s care has ended
  • You must be satisfied that the person providing care has the appropriate qualifications, skills and experience to provide safe care for the patient.

Just as important as communication is record keeping and accountability; explaining observations and actions taken. This is not only important to ensure the patient gets the best care, but also to protect ourselves since we are accountable in the following areas:

  • To the profession for maintaining the standards in the General Medical Council’s code of conduct
  • To the public under both criminal and civil law for the safety of patients
  • To our employers under employment law.

We took two actions to work towards a best practice handover;

1. We introduced a dedicated electronic handover template (figure 2) requiring key information including patient location, responsible consultant, duty consultant, management plan and any outstanding jobs. This follows the recommendations and guidelines (figure 1) from the Royal College of Physicians (RCP)[iii], Royal College of Surgeons (RCS)[iv] and the British Medical Association (BMA)[v]

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Figure 1: British Medical Association/Royal College of Physicians/Royal College of Surgeons guidelines on written handover

2. A simple monitoring exercise was conducted over four weeks where juniors were asked to sign at the start of their on-call duty if they were happy with the handover they received and felt able to adequately continue patient care. Only seven of the 28 days (25%) had handover signed by junior doctors.

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Figure 2: Example dedicated handover template trialled

We undertook focused teaching sessions and incorporated a 15-minute crossover period for handover in our rotas, with registrars intermittently supervising handover to provide constructive personal feedback and ensure high standards were maintained.

A second cycle of 56 days was monitored, showing an improvement with 41 days (73%) signed.

Assuming signatures related to effective handover, our results showed improved handover with simple measures. This continuous monitoring can improve and maintain high standards of handover and is easily replicable across other departments.

Got your thoughts or ideas about handover? Join junior doctors Jennifer Perry, Avi Mehra, Christin Henein, and BMJ Quality on Wednesday 29th April 17:30-18:30 GMT for a Tweet chat as they share their experiences of handover projects. Full information available here.

[i] http://www.themdu.com/guidance-and-advice/latest-updates-and-advice/gmc-publishes-new-good-medical-practice

[ii] http://www.rcseng.ac.uk/news/new-good-surgical-practice-published-by-rcs#.VQDAxELA4dU

[iii] Metz D, Chard D, Rhodes J, Pounder P. Continuity of care for medical inpatients: standards of good practice 2004 London Royal College of Physicians

[iv] The Royal College of Surgeons of England (2007) Safe handover: guidance from the Working Time Directive working party (RCS, London) www.rcseng.ac.uk/publications/docs/publication.2007-05-14.3777986999/.

[v] British Medical Association (2004) Safe handover: safe patients. Guidance on clinical handover for clinicians and managers (BMA, London).