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.