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.

Schwartz Rounds for Staff in an Australian Tertiary Hospital: Protocol for a Pilot Uncontrolled Trial

BACKGROUND

Schwartz Rounds are a unique, organization-wide interdisciplinary intervention aimed at enhancing staff well-being, compassionate care, teamwork, and organizational culture in health care settings. They provide a safe space wherein both clinical and nonclinical health staff can connect and share their experiences about the social and emotional aspects of health care.

OBJECTIVE

Although Schwartz Rounds have been assessed and widely implemented in the United States and United Kingdom, they are yet to be formally evaluated in Australian health care settings. The purpose of this study is to evaluate the feasibility and impact of Schwartz Rounds on staff well-being, compassionate care, and organizational culture, in a tertiary metropolitan hospital in Brisbane, Australia.

METHODS

This mixed methods repeated measures pilot study will recruit 24 participants in 2 groups from 2 departments, the intensive care unit and the gastroenterology department. Participants from each group will take part in 3 unit-based Schwartz Rounds. Primary outcomes will include the study and intervention feasibility measures, while secondary outcomes will include scores on the Maslach Burnout Inventory-Human Services Survey, the Schwartz Centre Compassionate Care Scale, and the Culture of Care Barometer. Primary and secondary outcomes will be collected at baseline, after the Rounds, and 3-month follow-up. Two focus groups will be held approximately 2 months after completion of the Schwartz Rounds. Descriptive statistics, paired t tests, chi-square tests, and analysis of variance will be used to compare quantitative data across time points and groups. Qualitative data from focus groups and free-text survey questions will be analyzed using an inductive thematic analysis approach.

RESULTS

The study was approved by the Mater Hospital Human Research Ethics Committee (reference number: HREC/MML/71868) and recruitment commenced in July 2021; study completion is anticipated by May 2022.

CONCLUSIONS

The study will contribute to the assessment of feasibility and preliminary efficacy of the Schwartz Rounds in a tertiary Australian hospital during the COVID-19 pandemic.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12621001473853; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382769&isReview=true.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/35083.

Avoiding Difficult Conversations in the Australian Health Sector

Background

Health professionals avoiding difficult conversations with each other can lead to serious negative consequences for patients. Clinical supervisors are in the unique position of interacting both with students as well as colleagues and peers. This study explores the avoidance of difficult conversations from the perspective of clinical supervisors in order to better understand why health professionals avoid difficult conversations.

Objective

This study aimed to identify the reasons why difficult conversations are avoided between health-care professionals and to gain deeper insight into the phenomenon of avoiding difficult conversations in general.

Methods

Convergent interviewing was used with 20 clinical supervisors to explore the following question: Why do you think that people in your workplace avoid difficult conversations?

Results

Major reasons for avoiding difficult conversations included the fear of negative consequences, a general distaste for confrontation, and a lack of confidence in their skills to have such conversations. Additional factors included individual qualities such as personality type and communication style, available time, size of the workplace, and a range of perceived cultural barriers standing in the way of having difficult conversations.

Conclusion

There is a need to encourage clinical supervisors and other health professionals to embrace difficult conversations to reduce adverse events and enhance patient outcomes. This requires additional training and educational opportunities to enhance knowledge, skills, and confidence to plan and engage in difficult conversations. Some types of difficult conversations require more skills than others.

A realist informed mixed-methods evaluation of Schwartz Center Rounds® in England

Background

Schwartz Center Rounds®(Rounds) were introduced into the UK in 2009 to support health-care staff to deliver compassionate care, something the Francis report (Francis R.Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office; 2013) identified as lacking. Rounds are organisation-wide forums that prompt reflection and discussion of the emotional, social and ethical challenges of health-care work, with the aim of improving staff well-being and patient care.

Objectives

How, in which contexts and for whom Rounds participation affects staff well-being at work, increases social support for staff and improves patient care.

Design

(1) A scoping review of Rounds literature and comparison with alternative interventions; (2) mapping Rounds providers via a survey, telephone interviews and secondary data; (3) a two-wave survey of (i) new attenders/non-attenders in 10 sites to determine the impact on staff engagement and well-being; and (ii) interviews with Rounds attenders, non-attenders, facilitators, clinical leads, steering group members, board members and observations in nine case study sites to (4) describe experiences and (5) test candidate programme theories by which Rounds ‘work’ (realist evaluation).

Setting

(1) International literature (English); (2) all Rounds providers (acute/community NHS trusts and hospices) at 1 September 2014 (survey/interview) and 15 July 2015 (secondary data); (3) 10 survey sites; and (4 and 5) nine organisational case study sites (six of which also took part in the survey).

Participants

(1) Ten papers were reviewed for Rounds and 146 were reviewed for alternative interventions. (2) Surveys were received from 41 out of 76 (54%) providers and interviews were conducted with 45 out of 76 (59%) providers. (3) Surveys were received from 1140 out of 3815 (30%) individuals at baseline and from 500 out of 1140 (44%) individuals at follow-up. (4 and 5) A total of 177 interviews were conducted, as were observations of 42 Rounds, 29 panel preparations and 28 steering group meetings.

Results

(1) The evidence base is limited; compared with 11 alternative interventions, Rounds offer a unique organisation-wide ‘all staff’ forum in which disclosure/contribution is not essential. (2) Implementation rapidly increased between 2013 and 2015; Rounds were implemented variably; challenges included ward staff attendance and the workload and resources required to sustain Rounds; and costs were widely variable. (3) There was no change in engagement, but poor psychological well-being (12-item General Health Questionnaire) reduced significantly (p < 0.05) in Rounds attenders (25% to 12%) compared with non-attenders (37% to 34%). (4 and 5) Rounds were described as interesting, engaging and supportive; four contextual layers explained the variation in Rounds implementation. We identified four stages of Rounds, ‘core’ and ‘adaptable’ components of Rounds fidelity, and nine context–mechanism–outcome configurations: (i) trust, emotional safety and containment and (ii) group interaction were prerequisites for creating (iii) a countercultural space in Rounds where staff could (iv) tell stories, (v) self-disclose their experiences to peers and (vi) role model vulnerability; (vii) provide important context for staff and patient behaviour; (viii) shining a spotlight on hidden staff and patient stories reduced isolation and enhanced support/teamwork; and (ix) staff learned through reflection resulting in ripple effects and outcomes. Reported outcomes included increased empathy and compassion for colleagues and patients, support for staff and reported changes in practice. The impact of Rounds is cumulative and we have identified the necessary conditions for Rounds to work.

Limitations

Rounds outcomes relied on self-report, fewer regular attenders were recruited than desired, and it was not possible to observe staff post Rounds.

Conclusion

Rounds offer unique support for staff and positively influence staff well-being, empathy and compassion for patients and colleagues.

Future work

The adaptation of Rounds to new contexts and to increase reach needs evaluation.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Can Schwartz Center Rounds support healthcare staff with emotional challenges at work, and how do they compare with other interventions aimed at providing similar support? A systematic review and scoping reviews

OBJECTIVES

(i) To synthesise the evidence-base for Schwartz Center Rounds (Rounds) to assess any impact on healthcare staff and identify key features; (ii) to scope evidence for interventions with similar aims, and compare effectiveness and key features to Rounds.

DESIGN

Systematic review of Rounds literature; scoping reviews of comparator interventions (action learning sets; after action reviews; Balint groups; caregiver support programme; clinical supervision; critical incident stress debriefing; mindfulness-based stress reduction; peer-supported storytelling; psychosocial intervention training; reflective practice groups; resilience training).

DATA SOURCES

PsychINFO, CINAHL, MEDLINE and EMBASE, internet search engines; consultation with experts.

ELIGIBILITY CRITERIA

Empirical evaluations (qualitative or quantitative); any healthcare staff in any healthcare setting; published in English.

RESULTS

The overall evidence base for Rounds is limited. We developed a composite definition to aid comparison with other interventions from 41 documents containing a definition of Rounds. Twelve (10 studies) were empirical evaluations. All were of low/moderate quality (weak study designs including lack of control groups). Findings showed the value of Rounds to attenders, with a self-reported positive impact on individuals, their relationships with colleagues and patients and wider cultural changes. The evidence for the comparative interventions was scant and also low/moderate quality. Some features of Rounds were shared by other interventions, but Rounds offer unique features including being open to all staff and having no expectation for verbal contribution by attenders.

CONCLUSIONS

Evidence of effectiveness for all interventions considered here remains limited. Methods that enable identification of core features related to effectiveness are needed to optimise benefit for individual staff members and organisations as a whole. A systems approach conceptualising workplace well-being arising from both individual and environmental/structural factors, and comprising interventions both for assessing and improving the well-being of healthcare staff, is required. Schwartz Rounds could be considered as one strategy to enhance staff well-being.

Evaluating Schwartz Center Rounds® in an urban hospital center

Purpose

– Schwartz Center Rounds® (SCRs) bring multidisciplinary caregivers together to discuss authentic patient cases from the social and emotional perspective. The monthly sessions provide a forum to share personal thoughts and feelings. The purpose of this paper is to learn why people attend SCR, understand what is gained from the experience, and identify key elements to use in measuring the program’s effectiveness.

Design/methodology/approach

– This qualitative descriptive study used four focus groups and three telephone interviews for data collection. Purposive sampling resulted in a multidisciplinary sample of 30 participants. Thematic analysis was conducted with complete transcripts by all researchers.

Findings

– All parties viewed SCR as beneficial. Six themes emerged during data analysis: culture change, exposing emotions, walking in another’s shoes, inequality of topics, influence of rules and boundaries, and personal impact. Institutional culture was positively influenced through SCR.

Research limitations/implications

– Limitations include a single institution and restricted data gathered from physicians. Future research should focus on identifying outcome measures to evaluate the long-term impact of SCR on healthcare organizations.

Practical implications

– This study confirms that the SCR program should be continued at the study organization, and expanded to increase availability to all staff. The growth of this program in healthcare organizations across the country is encouraged.

Originality/value

– This research provides support for healthcare organizations to offer SCR and highlights how the emotional aspects of patient care can be acknowledged, explored, and discussed.