Schwartz rounds have been shown to improve staff wellbeing and patient care; it’s time for them to be rolled out, says Richard Smith
Providing humane, compassionate care to multiple sick people in busy hospitals and clinics can be difficult, and sometimes health staff fail to do so. Schwartz rounds are a simple means to support staff to provide humane, compassionate care, and a mixed methods evaluation for the National Institute for Health Research has shown benefits for “staff well-being, empathy and compassion for patients and colleagues.” Rounds are now held in over 200 NHS organisations and in many more health organisations in the US, where they were first developed.
I’ve recently become the unpaid chair of the Point of Care Foundation, which brought Schwartz rounds to Britain and Ireland, and I’ve been finding out more about them. I’ve attended two rounds, talked to those who organise them, and read about them. The mission of the Point of Care Foundation is to promote humane compassionate care, recognising that for staff to deliver such care they need to be treated humanely and compassionately themselves. Too often in the NHS they are not.
The origins of Schwartz rounds
Schwartz rounds began with a legacy from Ken Schwartz, a health lawyer who died of lung cancer in 1995. He was diagnosed with advanced lung cancer in November 1994 when he was aged 40, and he and his family were terrified. But, as he describes in an article in the Boston Globe, he experienced “moments of exquisite compassion” from some health staff and “simple human touch . . . made the unbearable bearable.”
Schwartz described many moments of compassion in his article, and below he describes a meeting with a nurse who “was cool and brusque, as if I were just another faceless patient” when they first met but then changed:
“We talked about my 2-year-old son, Ben, and she mentioned that her nephew was named Ben. By the end of our conversation, she was wiping tears from her eyes and saying that while she normally was not on the surgical floor, she would come see me before the surgery. Sure enough, the following day, while I was waiting to be wheeled into surgery, she came by, held my hand, and, with moist eyes, wished me luck.
“This small gesture was powerful; my apprehension gave way to a much- needed moment of calm. Looking back, I realize that in a high-volume setting, the high-pressure atmosphere tends to stifle a caregiver’s inherent compassion and humanity. But the briefest pause in the frenetic pace can bring out the best in a caregiver and do much for a terrified patient.”
Schwartz understood that staff need support to provide humane, compassionate care, and Schwartz rounds are designed to that end. They are for staff not patients and follow a simple formula. They are an hour long, usually held monthly at lunchtime with food, multidisciplinary, confidential, and not about clinical issues or solving problems but about allowing staff to explore their feelings and emotions and reflect on how they relate to patients. The aim is to promote compassionate care and improve staff wellbeing.
The rounds start with three people, preferably from different disciplines, telling stories around a theme—perhaps “when things go wrong” or “a patient I’ll never forget.” The emphasis is on the emotions the staff felt. Trained facilitators then lead a discussion, asking people to share their reactions to the stories and their own stories. The facilitators ensure that the conversation remains reflective and does not become about solving problems.
Two Schwartz rounds
I attended two Schwartz rounds, one in a hospice and one in an acute trust. They were more similar than dissimilar: both had about 30-40 people attending from all disciplines; both places have been holding them monthly for several years; and the feel of the two was similar with people sharing difficult professional and personal stories. They held my attention, and I felt that everybody was listening hard. Nobody looked at their phones. Nobody had a laptop.
I couldn’t help but notice that in both rounds women were the main contributors. Indeed, in one round the only man who spoke from the audience made observations about his team rather than sharing his own vulnerability. (I’m told that this isn’t true of all rounds.) Both rounds included healthy silences when people reflected on what they had heard and gathered courage to share something.
The topic for the round in the hospice was “reality bites,” and the three presenters told stories of emotions hitting them strongly and suddenly. People worried that showing emotion might be thought of as unprofessional. Several people described how emotion had hit them hard and unexpectedly when something in their professional lives coincided with their personal lives—dying patients from families that reflected their own families, a person with a disease that a parent died from, dying people who were born in the same year as the member of staff. Sometimes people were prompted to look back on previous experiences and thought how they could have handled them much better.
People were unsure what to do when reality bites. There is a tendency to try and “seal it off” but is the experience then ever dealt with? Isn’t it healthy to feel emotion? Is it right to suppress the emotion, to deny it?
Professional staff described how they had been trained not to get too close to anybody and taught that medicine is full of uncertainty and that becoming emotionally involved with patients would made work exponentially harder. You should separate home from work. In effect, you should be two different people.
Yet the consensus was that emotion was all right and that “you can’t not be a whole person” if you want to care well for people, although there was a feeling that that was harder to achieve in an acute hospital than in a hospice.
Everybody who spoke had been “bitten by reality,” and, of course, we all are at some stage. I reflected on my father dying and good friends that I don’t see anymore. Reality biting produces pain but also a chance to learn and grow. One of the speakers concluded, “It’s OK to feel sad, it’s OK to have a bad day, and it’s OK not to feel OK.”
The topic for the round in the acute trust concerned safeguarding. All three speakers—one a doctor, one a manager, and one a technician—had been involved with a case where a controlling father refused to accept treatment for his child that, to the hospital staff, was obviously beneficial for the child. He made complaints against the staff, but was irrational in conversations about his complaint, one minute saying he would go to the law, the next minute praising the staff.
All the staff described remembering the case “as if it was yesterday” despite it having happened some 18 months before the round. The staff had felt sad, angry, and powerless. The experience left scars. One felt that her own relationships had been damaged.
Several people in the audience described similar experiences with difficult family members and patients. All felt powerless and were unsure what to do. You want to help, but you can’t, observed a speaker. You feel guilty about not being able to help and blame yourself for the position you are in. You keep trying to find a solution and feel you have failed. It knocks your confidence. Staff are not taught how to deal with a difficult patient or relative.
You want to solve things, but in these circumstances you can’t, said another speaker. It’s really hard to say you feel powerless and then not have a plan to put it right. People in healthcare want to help, and it’s very hard when you can’t.
As I listened to the two rounds I thought of a blog I wrote about a famous paper published in 1960 by Isabel Menzies Lyth, a psychoanalyst, who was asked to advise on why a nursing service in a general hospital was on the point of breakdown. She observed that working all day with patients who are suffering, in pain, and dying is extremely hard—indeed, unnatural. As a result staff are likely to develop defences that are essential for emotional survival but not optimal for patient care. Schwartz rounds seem to me to be an intervention that allows people to share the difficulties and emotional challenges of patient care and avoid developing pathological defences that can harm patient care.
Rounds are held not only in hospices and acute hospitals but also in primary care, community and mental hospitals, and educational settings—and there is demand from prisons, children’s social care, vets, and the police. Increasingly it seems that they can be held almost anywhere where there are emotional challenges in the work.
Evidence for Schwartz rounds
The spread of the rounds in the NHS, and in the US, and the fact that once having started them most organisations continue with them is evidence for the benefit of the rounds, and the study for the National Institute of Health Research provides more formal evidence. The team that did the study compared Schwartz rounds with 11 other interventions, including Balint Groups, resilience training, after-action reviews, action learning sets, critical incident stress debriefing, caregiver support programmes, mindfulness based stress reduction, and reflective practice groups. The team used several methods including a scoping review, telephone interviews, and a survey of (and interviews with) attendees, non-attendees, and many others, like facilitators and managers, involved in the rounds.
The team found more evidence supporting Schwartz rounds than any of the other interventions and concluded that “rounds offer unique features that none of the alternatives provides.” While recognising the limitations of their study and the need for more research the team’s overall conclusion was that “[Schwartz] Rounds offer a safe, reflective space for staff to share stories with their peers about their work and its impact on them. Attendance is associated with a statistically significant improvement in staff psychological well-being. Reported outcomes included increased empathy and compassion for patients and colleagues and positive changes in practice.”
Conclusion
With staff shortages and increased pressure on the NHS it may become even more difficult for staff to consistently provide humane and compassionate care. Schwartz rounds are a simple, easily implemented way to support staff in providing compassionate humane care and improve their own wellbeing.
You can watch a video of a Schwartz round here.
If you would like to attend a Schwartz round contact a local NHS organisation that runs them or Farhana Nargis at the Point of Care Foundation.
Richard Smith was the editor of The BMJ until 2004.
Competing interest: RS is the unpaid chair of the Point of Care Foundation. The foundation, which is a registered charity, holds the licence for Schwartz rounds in the UK and Ireland; provides training; supports facilitators; and charges for the rounds, training, and support.