Introducing compassion into the education of health care professionals; can Schwartz Rounds help?

How Does a Group Reflection Intervention (Schwartz Rounds) Work within Healthcare Undergraduate Settings? A Realist Review

Introduction

Schwartz Rounds ("Rounds") are a confidential group reflection forum, increasingly adopted to support pre-registration healthcare students. This realist review aims to understand what the available literature and key informant interviews can tell us about Rounds in this setting, asking what works, for whom, in what circumstances, and why?

Methods

Published literature discussing Rounds in undergraduate settings were analysed using realist methods to describe how, for whom and in which contexts Rounds work. Four key informants were interviewed using realist methods, to further develop, test and refine a programme theory of Rounds in undergraduate settings.

Results

We identified five core features and five contextual adaptations.Core: Rounds provide a reflective space to discuss emotional challenges; Rounds promote an open and humanised professional culture; Rounds offer role-modelling of vulnerability, enabling interpersonal connectedness; Rounds are impactful when focused on emotional and relational elements; Rounds offer reflective insights from a wide range of perspectives.Contextual adaptations: Rounds allow reflection to be more engaging for students when they are non-mandatory; perceptions of safety within a Round varies based on multiple factors; adapting timing and themes to students' changing needs may improve engagement; resonance with stories is affected by clinical experience levels; online adaptation can increase reach but may risk psychological safety.

Discussion

Schwartz Rounds are a unique intervention that can support healthcare students through their pre-registration education. The five "core" and five "contextual adaptation" features presented identify important considerations for organisations implementing Rounds for their undergraduates.

How to organise and run Schwartz rounds

RATIONALE AND KEY POINTS

Schwartz rounds are a group-based model of reflective practice originally designed to assist medical staff to develop more compassion in their care. The aim of Schwartz rounds is to help healthcare professionals such as nurses 'reconnect' with why they first entered the caring profession. • Schwartz rounds are designed to assist multidisciplinary healthcare professionals with the emotional, social and ethical aspects of caregiving. • Schwartz rounds can also be used to support resilience training and boost workforce morale. • The use of Schwartz rounds can assist nurses to understand the moral challenges they may encounter while caring for patients. REFLECTIVE ACTIVITY: 'How to' articles can help to update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of: • How this article might help you organise Schwartz rounds in your clinical area. • How you could use this information to educate your colleagues about Schwartz rounds.

Early introduction of the multi-disciplinary team through student Schwartz Rounds: a mixed methodology study

BACKGROUND

Medical education has changed continually throughout the covid-19 pandemic, creating additional stress for medical students. Personal reflection can empower an individual to adapt to new challenges, and reflection has gradually become incorporated into medical student training. Schwartz Rounds (SR) offer a compassionate group reflective forum for healthcare staff. SRs have been extensively introduced throughout the NHS, however medical student rounds are yet to be widely adopted. Entirely unresearched is how the multi-disciplinary team impacts a medical student SR. This study aims to compare medical student experience of a single-discipline and a multi-discipline SR using mixed methodology.

METHODS

Two virtual SRs were run at an NHS district general hospital, using the existing structure of the Trust's rounds. The first round included only medical students on placement at the hospital, whereas the second round also involved other student health disciplines. Following each round Likert scale questionnaires were collected, and focus groups were held with a small number of participants. Quantitative analysis used median averages as well direct comparison of scores for each round. Qualitative data from the focus groups underwent thematic analysis.

RESULTS

The quantitative data showed a positive response to both styles of student SRs, with over 87% of participants at both rounds stating they intended to attend further rounds. Direct comparison between the two rounds showed higher feedback scores for the single-discipline round. Qualitative analysis showed strong student interest in further group reflection, noting the value of SRs in improving workplace culture and inter-professional relationships. The analysis also highlighted frustrations with the existing SR structure, namely large group sizes and scripted panellists.

CONCLUSIONS

Both data sets showed a strong positive response to SRs, and a desire to attend again. There is some evidence to suggest the addition of multiple student disciplines at SRs impaired medical student reflection. Changes to the format of the round could result in even greater success in student rounds.

The The Difficult Case Consultation: An intervention for interprofessional health communication

An interprofessional group of healthcare practitioners sought a new approach to the early detection, prevention, and resolution of “difficult cases” in the inpatient care context. An action research project addressed this need by developing a narrative re-framing tool that helped reveal entrenched assumptions regarding the root causes of difficult cases in the hospital. The intervention method that emerged from the project — the Difficult Case Consultation (DCC) — is a theoretically-grounded process that helps teams to analyze and address complex communication problems in interprofessional healthcare contexts. Collaborative processes grounded in theory have proven to be the most successful when seeking to optimize healthcare team communication. The article describes the collaborative development of the DCC, presents two cases illustrating the process, and describes systemic factors that exacerbated the emergence of difficult cases in the inpatient context.

Other-Focused Approach to Teaching. The Effect of Ethical Leadership and Quiet Ego on Work Engagement and the Mediating Role of Compassion Satisfaction

Recent revisions of the Job Demands Resources (JDR) model acknowledged the importance of personal and organizational dimensions enriching job resources' effect on work engagement. Consistently, this paper addresses the role of compassion satisfaction, as a job resource, on teacher work engagement, given the saliency of caring in teaching as a helping profession. Furthermore, quiet ego, as a personal dimension, and ethical leadership, as an organizational dimension, are studied as antecedents of compassion satisfaction. Overall, the study verifies with a Structural Equation Model whether and how compassion satisfaction mediates the relationships among work engagement, quiet ego, and ethical leadership. One hundred and eighty-eight Italian teachers took part in the study by completing four scales: the Ethical Leadership Scale, the Quiet Ego scale, the Professional Quality Of Life Questionnaire, and the Utrecht Work Engagement Scale-ultra-short version. The final model showed a good fit to the data: χ2 ( 48 ) = 75.399, p = 0.007, CFI = 0.979, TLI = 0.971, RMSEA = 0.055 (90% CI = 0.029-0.078, p = 0.342), SRMR = 0.039. Findings showed that teachers' compassion satisfaction is strongly related to their engagement at school, confirming that teachers' care toward their students is an important resource supporting their engagement. Furthermore, compassion satisfaction totally mediates the relationship between quiet ego and work engagement (bDIRECT = ns, bINDIRECT = 0.327, p = 0.000). Such mediating path confirms recent expansions of the JDR model about the role of personal resources on job resources and, consequently, on work engagement and confirms the Conservation of Resources theory, stating that personal resources impact work outcomes. At the same time, compassion satisfaction does not mediate the relationship between ethical leadership and work engagement, so that ethical school leaders directly impact teachers' work engagement. A possible reason for this finding relies on ethical leadership's role in promoting higher school life participation as a community. More theoretical and practical implications are described in the paper.

The Schwartz Centre Rounds: Supporting mental health workers with the emotional impact of their work

In healthcare settings, there is an emotional cost to caring which can result in compassion fatigue, burnout, secondary trauma, and compromised patient care. Innovative workplace interventions such as the Schwartz Rounds offer a group reflective practice forum for clinical and non-clinical professionals to reflect on the emotional aspects of working in health care. Whilst the Rounds are established in medical health practice, this study presents an evaluation of the Rounds offered to mental health services. The Rounds were piloted amongst 150 mental health professionals for 6 months and evaluated using a mixed-methods approach with standardized evaluation forms completed after each Round and a focus group (n = 9) at one-month follow-up. This paper also offers a unique six-year follow-up of the evaluation of the Rounds. Rounds were rated as helpful, insightful, and relevant, and at six years follow-up, Rounds were still rated as valuable and viewed as embedded. Focus groups indicated that Rounds were valued because of the opportunity to express emotions (in particular negative emotions towards patients that conflict with the professional care-role), share experiences, and feel validated and supported by colleagues. The findings indicate that Schwartz Rounds offer a positive application in mental healthcare settings. The study supports the use of interventions which provide an ongoing forum in which to discuss emotions, develop emotional literacy, provide peer support and set an intention for becoming a more compassionate organization in which to work.

The lived experience of working with people with eating disorders: A meta-ethnography

OBJECTIVE

Working with people with eating disorders (EDs) is known to elicit strong emotional reactions, and the therapeutic alliance has been shown to affect outcomes with this clinical population. As a consequence, it is important to understand healthcare professionals' (HCPs') experiences of working with this client group.

METHOD

A meta-synthesis was conducted of qualitative research on HCPs' lived experiences of working with people with EDs. The results from the identified studies were analyzed using Noblit and Hare's meta-ethnographic method. Data were synthesized using reciprocal translation, and a line of argument was developed.

RESULTS

Thirty-seven studies met the inclusion criteria. Reciprocal translation resulted in a key concept: "Coping with caring without curing." This was underpinned by the following third-order concepts: (a) "The dissonance and discomfort of being a helper struggling to help," (b) "Defending against the dissonance," and (c) "Accepting the dissonance to provide safe and compassionate care." These concepts were used to develop a line-of-argument synthesis, which was expressed as a new model for understanding HCPs' experiences of working with people who have an ED.

DISCUSSION

Although the conflict associated with being a helper struggling to help led some HCPs to avoid and blame people with EDs, others adopted a compassionate stance characterized by humanity, humility, balance, and awareness.

A qualitative exploration of the experiences of students attending interprofessional Schwartz Rounds in a University context

Schwartz Rounds are a cultural change initiative for interdisciplinary staff to reflect on their work to preserve the human connection. Their recent implementation in educational contexts means that there is limited research exploring the experience of students attending Rounds. This study aimed to develop understanding of how health-care students experience participation at Schwartz Rounds in a University context. Using an Interpretative Phenomenological Analysis approach, semi-structured interviews were conducted with eight health-care students about their experience of attending Rounds. Three themes were identified: ambivalence about safety to share "would it reflect badly on me?"; unifying through sharing emotions "you're not alone in feeling that"; and space to question professional cultures "there's not normally space given to that". The findings suggest that Rounds promote connectedness through humanizing professions and focusing on shared emotions; however, safety to share within Rounds can be limited by fear of judgment. This supports previous literature and suggests that Rounds may be well placed in educational contexts to support cultural change from the beginning of training.

Learning and coping through reflection: exploring patient death experiences of medical students

BACKGROUND

Existing studies have explored many aspects of medical students' experiences of patient death and propose the importance of faculty support for coping. However, UK-based literature on this subject and research concerning learning through reflection as part of coping are relatively limited. This study, through the lens of reflection, aims to explore students' experiences with patient death in a UK context. These include coping strategies, support from faculty following patient death and the relationship between these experiences and learning. Our research questions were: How do medical students cope with and learn from their experiences?How does support from ward staff and the medical school help them cope with and learn from these experiences?How can students best be supported following patient death?

METHODS

We employed narrative inquiry to explore how medical students made sense of their experiences of patient death. Twelve students participated in our study via an online narrative questionnaire. Thematic analysis and complementary narrative analysis of an exemplar were applied to address our research aim.

RESULTS

Coping strategies comprised internal and external strategies. Internal strategies included (1) re-interpretation of the death into a meaningful experience including lessons learned; (2) normalization; (3) staying busy and (4) enduring negative emotions. External strategies included speaking to someone, which was found to influence normalization, and lessons learned. Both satisfactory and unsatisfactory support from ward staff was identified. Satisfactory support was characterized by the inclusion of emotional and professional support. Unsatisfactory support was often characterized by a lack of emotional support. Narrative analysis further demonstrated how the experience with patient death was re-interpreted meaningfully. Students suggested that support should be structured, active, sensitive, and include peers and near-peers.

CONCLUSION

Many coping strategies, internal and external, were employed in students' experiences with patient death. Student reflections, enhanced by support from ward staff, were shown to be important for learning from patient death. We encourage faculty to have regular sessions in which medical students can reflect on the death incident and discuss appropriately with others, including peers and near-peers.

Compassion in palliative care: a review

PURPOSE OF REVIEW

Compassion has been recognized as a key aspect of high-quality healthcare, particularly in palliative care. This article provides a general review of the current understanding of compassion in palliative care and summarizes emergent compassionate initiatives in palliative care at three interdependent levels: compassion for patients, compassion in healthcare professionals, and compassionate communities at the end of life.

RECENT FINDINGS

Compassion is a constructive response to suffering that enhances treatment outcomes, fosters the dignity of the recipient, and provides self-care for the giver. Patients and healthcare professionals value compassion and perceive a general lack of compassion in healthcare systems. Compassion for patients and for professionals' self-care can be trained and implemented top-down (institutional policies) and bottom-up (compassion training). 'Compassionate communities' is an important emerging movement that complements regular healthcare and social services with a community-level approach to offer compassionate care for people at the end of life.

SUMMARY

Compassion can be enhanced through diverse methodologies at the organizational, professional, and community levels. This enhancement of compassion has the potential to improve quality of palliative care treatments, enhance healthcare providers' satisfaction, and reduce healthcare costs.

The 'values journey' of nursing and midwifery students selected using multiple mini interviews: Evaluations from a longitudinal study

Values-based practice is deemed essential for healthcare provision worldwide. In England, values-based recruitment methods, such as multiple mini interviews (MMIs), are employed to ensure that healthcare students' personal values align with the values of the National Health Service (NHS), which focus on compassion and patient-centeredness. However, values cannot be seen as static constructs. They can be positively and negatively influenced by learning and socialisation. We have conceptualised students' perceptions of their values over the duration of their education programme as a 'values journey'. The aim of this hermeneutic longitudinal focus group study was to explore the 'values journey' of student nurses and midwives, recruited through MMIs, across the 3 years of their education programme. The study commenced in 2016, with 42 nursing and midwifery students, originally recruited onto their programmes through multiple mini interviews. At the third and final point of data collection, 25 participants remained. Findings indicate that students' confidence, courage and sense of accountability increased over the 3 years. However, their values were also shaped by time constraints, emotional experiences and racial discrimination. We argue that adequate psychological support is necessary as healthcare students embark on and progress through their values journey, and propose a framework for this.

Contraste de perspectivas y experiencias sobre compasión de enfermeras colombianas con 14 países

Se exploraron puntos de vista y experiencias sobre compasión en la práctica de enfermeras colombianas y contrasta con los otros 14 países participantes del estudio internacional online. El estudio transversal exploratorio con survey internacional online con 10 preguntas (abiertas y cerradas), contó con 1323 enfermeras, 103 fueron de Colombia. Datos cuantitativos colombianos fueron analizados en Excel y los cualitativos en el programa Nvivo con análisis temático y consenso entre investigadores. La muestra colombiana contó con 83,5% docentes y eligieron la definición de compasión como la “conciencia profunda de sufrimiento de los otros y el deseo de aliviar ese sufrimiento” (84,3%). Piensan que la compasión puede ser enseñada (64,1%) pero no es impartida (45,1%) y es influenciada por la experiencia personal (38,2%) y los valores culturales (37,3%).  Los relatos de Colombia revelan barreras sociopolíticos, organizacionales y educativos para la atención compasiva. Perciben compasión de sus pacientes (84,7%), escasa compasión entre colegas (14,3%) y casi nula compasión por parte de los gerentes (1%). Sin embargo, emerge la naturaleza consciente e intencional de la compasión y el esfuerzo de enfermería por desarrollarla en cinco componentes: particularizar, invertir tiempo, estar presente, ir más allá y la defensa/abogacia. Se hacen evidentes algunas variaciones culturales de la compasión y formas de promoverla en un ejercicio profesional cada vez más transcultural.

International study on nurses' views and experiences of compassion

BACKGROUND

Compassion is considered the cornerstone of nursing practice. However, the recent failures in delivering high-quality compassionate nursing care in the UK's National Health Service have brought the topic of compassion to the attention of the public, service providers, policy makers and academics.

AIM

The aim of this study was to explore the nurses' views and experiences of a number of compassion-related issues in nursing and describe similarities and differences at an international level as well as from the different nursing roles of the participating nurses.

METHODS

An exploratory, cross-sectional descriptive study, using the International Online Compassion Questionnaire. A total of 1323 nurses from 15 countries completed the questionnaire.

RESULTS

The majority of participants (59.5%) defined compassion as "Deep awareness of the suffering of others and wish to alleviate it" but definitions of compassion varied by country. Of participants, 69.6% thought compassion was very important in nursing and more than half (59.6%) of them argued that compassion could be taught. However, only 26.8% reported that the correct amount and level of teaching is provided. The majority of the participants (82.6%) stated that their patients prefer knowledgeable nurses with good interpersonal skills. Only 4.3% noted that they are receiving compassion from their managers. A significant relationship was found between nurses' experiences of compassion and their views about teaching of compassion.

CONCLUSION

Our study is unique in identifying the views and experiences of nurses from 15 different countries worldwide. The findings reveal that compassion is neither addressed adequately in nursing education nor supported in the practice environment by managers.

LIMITATIONS

Self-report bias was inherent to our survey study design. Furthermore, the individual cultural differences and similarities in the findings are difficult to extrapolate owing to the fact that our analysis was at country level, as well as at the level of the participating nurses.

IMPLICATIONS FOR NURSING POLICY

Understanding the influence of culture on nurses' views about compassion is critical in the current multicultural healthcare environment and merits further research. This will potentially drive changes in nursing education (ensuring that compassion is taught to nurses) and in the way healthcare leaders and managers foster a compassionate culture within their organizations (e.g. by leading by example and compassionate to their staff).

Enabling honest reflection: a review

BACKGROUND

Reflective practice provides a backbone to professionalism, a commitment to lifelong learning and competency-based education in the form of reflective portfolios. Changes in health care culture have promoted a move towards openness and reflection on challenging clinical encounters.

ISSUE

Engagement with reflection has historically proved challenging to clinical educators. This Faculty Development Review examines this using a case study from the UK in which a postgraduate trainee was asked to disclose their reflective portfolio by a patient's legal representation. Critics have consequently questioned whether the educational benefit of reflection warrants these potential legal implications. In the context of pressure from accrediting bodies to demonstrate evidence of reflection, how can learners face this potential conflict of professional versus legal repercussions?

EDUCATIONAL RATIONALE

We combine professional guidance from the UK and educational rationale from international settings to produce a guide for good practice. We offer guidance on facilitating reflection for learners in an open and honest way without diluting educationally effective critical reflection. Themes of anonymity, taking a balanced approach, seeking senior advice, focusing on learning outcomes and role-modelling are discussed. How can learners face this potential conflict of professional versus legal repercussions?

TAKE-HOME MESSAGES

Integrating reflection within the curriculum improves engagement and is key to experiential learning. Clinical educators should be aware of legal and professional guidance applicable to their own context. Both educators and learners should be aware that written reflection is an educational not a clinical tool, and so requires little or no patient-identifiable data, thereby ensuring safer reflective practice.