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Original research
Value of Schwartz Rounds in promoting the emotional well-being of healthcare workers: a qualitative study
  1. Lillian Ng1,2,
  2. Kiralee Schache3,4,
  3. Marie Young3,
  4. Joanna Sinclair5,6
  1. 1Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
  2. 2Mental Health and Addictions, Division of Psychiatry, Te Whatu Ora Health NZ Counties Manukau, Auckland, New Zealand
  3. 3Department of Psychological Medicine, Te Whatu Ora Health NZ Counties Manukau, Auckland, New Zealand
  4. 4Department of Critical Care, Te Whatu Ora Health NZ Counties Manukau, Auckland, New Zealand
  5. 5Department of Anaesthesia and Pain Medicine, Te Whatu Ora Counties Manukau, Auckland, New Zealand
  6. 6People and Culture Directorate, Te Whatu Ora Health NZ and Counties Manukau, Auckland, New Zealand
  1. Correspondence to Dr Lillian Ng; lillian.ng{at}auckland.ac.nz

Abstract

Objectives Schwartz Rounds are forums that enable healthcare staff to reflect on emotional and social dimensions of their work. In this study, we aimed to explore the experiences of Schwartz Rounds on emotional aspects of care and practice within a clinical environment.

Design Using qualitative methods, we interviewed participants individually and in focus groups. Interviews were recorded, transcribed and analysed by thematic analysis.

Setting The study was based at a public health service Te Whatu Ora Counties Manukau in Auckland, New Zealand’s largest, most ethnically diverse population.

Participants Participants were panellists who took part in successive Schwartz Rounds over a 10-month period. There were 17 participants with a range of experience (1–30 years) and occupations including clinical, allied, technical and administrative staff from medical specialties of plastic surgery, pain services, emergency medicine, intensive care, organ donation services, COVID-19 response and palliative care services.

Results Three themes were identified: the need for emotional processing, valuing guided reflection and realising our humanity. The third theme ‘realising our humanity’ comprised altruism, connection and compassion. Schwartz Rounds provided staff with clear benefits: emotionally resonant experiences within an environment of psychological safety and connection to the wider organisation. The daunting nature of emotional disclosure was mitigated by a supportive audience.

Conclusion There is an organisational imperative to ensure that staff have opportunities to process intense emotions associated with healthcare work. Schwartz Rounds are one means to attend to the emotional welfare of healthcare staff, enabling them to gain different perspectives in the care of their patients and colleagues within system constraints.

  • mental health
  • qualitative research
  • organisational development

Data availability statement

Data are available upon reasonable request. The authors report direct access to the study data. Access to transcripts of interviews with participants is ongoing and stored in accordance with University of Auckland Human Participants Ethics Committee guidelines. Data (deidentified transcripts and protocol) are available upon reasonable request and are available from the first author (ORCID number 0000-0002-7189-1272).

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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • Inclusion of a diverse range of participants from clinical, allied and technical specialties.

  • Member checking, cocoding of data and verification by an independent researcher.

  • Quotations are not attributed to individual participants and their role is not identified which limits comment on power dynamics within a healthcare hierarchy in focus group collection.

  • Limited participation from Māori and Pacific healthcare staff which restricts comment on holistic practices within a cultural context.

Introduction

In ordinary times, healthcare professionals face collective stress in caring for patients.1 The SARS-CoV2 pandemic has drawn attention to the psychological well-being of frontline healthcare staff workers amidst extraordinary pressures.2 3 Constraints on resources within hospital systems4 have resulted in professional distress and moral injury.5 Staff well-being correlates highly with good patient care6 and increasingly, healthcare organisations are taking measures to safeguard the psychological well-being of their employees.7

One such initiative is the Schwartz Round, an interdisciplinary forum that gives healthcare staff an opportunity to reflect on emotional and social dimensions of their work.8–10 Maben et al11 have comprehensively described the origins and structure of Schwartz Rounds and evidence of their effectiveness as an intervention to support health professionals experiencing emotional challenges working in healthcare. The emotional impact of Schwartz Rounds has been evaluated in acute, community, hospice and mental healthcare settings.12 13 These emphasised the importance of narrative and disclosure in understanding experiences of caring for others12 and the trust and empathy engendered in the process.13 Schwartz Rounds may enhance relationships and communication within and between teams of health professionals14–16 by enabling reflection on the demanding nature of healthcare and invite staff to process emotional material.17 Self-reflection is beneficial when people disclose and share emotions to understand traumatic events within conditions that engender psychological safety.11 18 Exploring emotional cues in healthcare enhances personal self-awareness, well-being11 and reduces psychological distress.9 It is also recommended as a useful skill to foster connection with patients.19 Building emotional resilience, or the capacity to recover from stressful events, contributes to sustaining compassion and the prevention of burnout at an individual level.20

From the perspective of healthcare professionals, compassion may be defined as ‘a virtuous, intentional response to know and understand a person, to discern their needs and ameliorate their suffering through relational understanding and action’.21 Compassion may include behaviours, skills, presence, understanding and emotional engagement. Encouraging a culture of compassion within a healthcare organisation may improve collegial relationships and teamwork.8 Schwartz Rounds may promote compassionate healthcare by strengthening emotional connections between staff and promoting teamwork, peer support and collegial understanding.11

In this study, we aimed to explore the experiences of Schwartz Rounds with regard to emotional aspects of care and practice within interdisciplinary teams in a unique and ethnically diverse catchment area in Auckland, New Zealand. The demographic of this location includes a high proportion of Māori and Pacific patients who view health within a wider mental, cultural, spiritual, environmental and family (whānau) context.22 We had the following research objectives: to assess participants’ response to a shared experience of facilitated reflection; to identify factors that supported healthcare workers to articulate their emotional needs and to explore Schwartz Rounds as a means to strengthen relationships with colleagues and support team cohesion.

Methods

This qualitative study has been conducted and reported according to standards for qualitative research.23

Study design and reflexivity

The study design was informed by interpretive description,24 a flexible approach to qualitative research that can be used to translate results to the context of clinical practice. The research team members are clinicians based at public hospital services, who work in academia, psychiatry, psychology and anaesthesia. Two authors are involved with systemic initiatives within healthcare services, aimed at improving staff well-being. All authors are involved with organising and/or facilitating Schwartz Rounds. In tandem with securing funding to conduct Schwartz Rounds, we evaluated staff engagement using survey resources provided as part of the Schwartz Round licence. We used qualitative methods to enquire more deeply about participants’ emotional experiences and to identify what further psychological support could be provided. As such, we acknowledge our investment in evaluating Schwartz Rounds and supporting discussion of emotional content associated with working in healthcare. To facilitate data collection, a psychiatrist (LN) and psychologist (MY) conducted the focus groups. To provide an objective lens, an independent researcher with expertise in qualitative methods (LL) cocoded transcripts and offered challenge during the analytic process.

Participants and data collection

We conducted qualitative interviews with staff following their participation in Schwartz Rounds. The participants were Schwartz Round panellists from five sequential Schwartz Rounds over a period of 10 months. Each panel involved 3–4 healthcare staff who were invited by a member of Te Whatu Ora Counties Manukau committee to speak on a specific theme. When participants agreed to be part of a Schwartz Round, they were invited in advance to take part in a focus group immediately after the Schwartz Round. Focus groups were selected as the preferred data collection method to encourage interaction and open dialogue within a group process.25 Two to 3 weeks prior to the Round, potential participants were emailed a participant information sheet and a copy of the consent form. Participants who were unable to attend a focus group were invited to an individual interview. Written consent was obtained from all participants immediately following the Schwartz Round, at which time the focus group convened. Four panellists were unable to attend two of the focus groups and were invited to attend an individual interview, which two participants accepted. All interviews took place at Auckland’s Middlemore Hospital.

Data analysis

Interviews were audio-recorded and transcribed. Participants had the option to have the transcripts returned for member-checking to verify their accuracy. Deidentified transcripts were entered into a computer-assisted database storage system (nVivo). Transcripts were read for initial familiarisation, then reread. Thematic analysis was performed as follows:26 there were three successive rounds of coding: (1) deidentified transcripts were cocoded separately by three members of the research team (LN, KS and JS) and an independent coder (LL); (2) initial themes from three successive focus groups were discussed by the research team; discrepancies were debated and themes were modified as consensus was achieved and (3) final themes were refined with the final Schwartz Round data from groups 4 and 5. In the third round of coding, an independent cocoder (LL) coded a proportion of the transcripts and reviewed the coding framework which was discussed among all coders. The final themes were agreed between all coders. We defined themes as recurrent and distinctive features of participants’ utterances,25 characterising their emotional experiences of the Schwartz Round. An audit trail was documented in nVivo, using the memoranda function, containing questions and reflections in discussions.

Patient and public involvement

There were no patients or members of the public involved in the research.

Results

Seventeen participants (11 women, 6 men) from five Schwartz Rounds took part in four focus groups and two individual interviews (table 1). Experience in their respective roles ranged from 1 to 30 years and the number of years worked at the district health board ranged from 1 to 30. Our Schwartz Rounds included a wide range of occupations such as senior medical officers, nurses, managerial staff, physiotherapists, occupational therapists, social workers, security staff, ward clerk, an orderly and a cleaner. Medical specialties included plastic surgery, pain services, emergency medicine, intensive care, organ donation services, COVID-19 response and palliative care services. From the data, we identified three main themes: the need for emotional processing, valuing guided reflection and realising our humanity.

Table 1

Participant characteristics

Need for emotional processing

The participants viewed the Schwartz Round as unique in providing a forum to intentionally focus on social and emotional aspects of patient care:

The process of sitting down and being forced to reflect…is a good thing. Maybe it’s a male thing, often we don’t tend to stop and take stock of what’s happened (FG4).

Some participants spoke of having technical expertise but fewer skills and opportunities to reflect on emotional qualities in being healthcare professionals, we had so many people emotionally breaking down in the meeting rooms.

Reflective practice is heavily encouraged… I think I do need to think more deeply about the emotion of the situation (II).

Participants who were clinicians were aware that individual, team or external supervision could help develop understanding of emotions associated with their work:

To hear [the psychologist] talk about how they have their supervision and for us to have that, would be so helpful. One simple thing that would make a huge difference (FG3).

As the process of the Schwartz Round unfolded, some participants articulated they had avoided difficult feelings:

I got a lot of benefit out of it. I didn’t think I’d get so emotional…obviously a few things going on there that had just been buried (FG2).

However, participants were surprised to find the experience therapeutic and helped some to feel more positive about their patients:

Being involved in this has forced me to reflect…makes me feel totally different about [the patient] (FG1).

Several participants acknowledged negative longer term consequences of not delving deeper into, avoiding or holding onto painful feelings. Many identified the need to divest themselves emotionally in some way, so they could maintain their home life and families:

The problem with me putting up all those walls around myself was that I found them hard to take down when I got home…I thought it would shield me at work, what happened was that when I got home I was totally disconnected from everybody (FG3).

Some participants were relieved to discover common ground in their team:

Just recognising that it is okay to show emotions… being given the opportunity that it’s actually okay, it’s normal, it will help you to move on and process (FG3).

Participants described feeling contained by an environment of psychological safety during the Schwartz round, which made them feel more able to share personal feelings:

It felt very well controlled, thank you. The phone calls leading up to it, you explained it, so we had a bit of an idea. It was a cathartic experience… I did feel safe (FG1).

All participants emphasised the facilitator’s role as important in preparing for the Schwartz Round and creating a safe environment to speak.

Valuing guided reflection

Some participants described the formal opportunity to reflect on their experiences as a unique opportunity to reflect on challenges in caring for patients in contrast to problem solving and analysing clinical management, the first formal channel or platform to discuss the case together. Many commented that they more commonly engaged in informal debriefing or talking about cases socially, offloading with colleagues.

You might have a chat to one of your colleagues walking down to the change room but you don’t often to get the opportunity to go into depth and into other people’s perspective of the situation (FG3).

More than half of participants acknowledged that a form of reflection for complex cases and sentinel events was important to sustain working in healthcare:

There’s no real structured opportunity to offload it unless you seek it yourself. I definitely know lots of people that are falling through the cracks and some people are leaving the job, the workplace because it’s just too much (FG3).

Despite benefits of reflective practice with their team or department, participants articulated the practical difficulty of organising it:

You have a resus, then maybe another one, then you’re going off shift. The last thing you want to do is take another half an hour at the end of your shift (FG2).

The majority of participants described taking part in Schwartz rounds as a positive experience. This included the process of being invited to participate, reflection on what they would speak to the audience about and support and validation from the staff members who attended. The participants also endorsed organisational investment in the Schwartz Round as a way of signalling that psychological safety of all staff as a priority and the emotional nature of their work was acknowledged.

Realising our humanity

This theme comprised three subthemes: altruism, connection and compassion. Many participants described appreciating decency and care from colleagues and feeling strongly connected to their teams. Participants identified self-compassion as caring for themselves to sustain care for patients amidst system difficulties.

Humanity through altruism

Several participants described Schwartz Rounds as a means to break down silos in care:

I never fully appreciated the dedication and the genuine desire to provide top-level healthcare… people day in and day out who are genuinely doing their best and trying to make a difference (FG4).

Some participants found the prospect of speaking at a Schwartz Round daunting and anxiety-provoking; others described being confronted, intimidated and somewhat embarrassed to have shared intense feelings more deeply than intended:

I’m more than happy to get up in front of 200, 300 people and public speak, no problem whatsoever. I’ve done it numerous times but doing what we did today, that was hard (FG2).

However, several participants reflected that they were glad they were honest about their feelings despite their reservations, particularly as they felt junior staff would benefit from emotional disclosure.

If you can model a certain behaviour, that it’s acceptable to show emotion … that [emotion] wouldn’t be something I would usually show but if you’re going to do it, you may as well do it right (FG3).

The Schwartz Rounds’ focus on human dimensions of their work led one participant to comment, we are emotional beings and that needs to be acknowledged.

Humanity through connection

Some participants reported stress and workload pressures that contributed to ruptured connections across the hospital, with staff feeling isolated in their own specialties. One participant described the Schwartz Round as ‘brilliant…a catalyst for better connection’.

We have the values of kindness, of togetherness. This is a way that we can start to normalise caring and vulnerability…for people to talk about things that matter is incredibly enriching to our [hospital] culture (II).

The participants described feeling supported by staff who attended as audience members. This allayed initial concern from participants that they would be judged by their colleagues. The audience contributions resulted in participants’ perceiving greater appreciation of their work:

It’s really forming those connections that give me the most enjoyment out of work and let me keep coming back (FG3).

Several saw a need to build ‘a safety net’ for all staff but acknowledged the practical difficulty of meeting that need:

It’s having that ability to self-reflect…getting the nurses, security, cleaners, health care assistants, you’d be surprised how many people are involved in bad stuff when it happens and getting them together—it’s just a logistical nightmare (FG2).

Amidst difficult working conditions during the coronavirus pandemic, some participants reflected on increased level of stress:

We didn’t plug into a warm heart a lot of the time during lockdown the first time. Staff were acrimonious and there was a lot more uncertainty (FG4).

Due to restrictions imposed by a national lockdown, two of the Schwartz Rounds were held in a virtual format, which curtailed the intimacy formed with a face-to-face audience:

If there were people here, even though I would have been more nervous, I would have felt that I could have connected with them better somehow (FG4).

Some participants found that preparing for Schwartz Rounds helped them reflect on humour and resilience within their teams and more uplifting aspects of patient care.

Humanity through compassion

Participants defined compassionate care in various ways: self-compassion, compassionate disposition, empathy with patients and compassionate systems which enabled them to sustain the arduous nature of the work.

Many participants were aware of the emotional toll of working in healthcare, the need to prioritise self-care and fortify themselves emotionally:

To be compassionate, you need to be truly compassionate for yourself…you cannot have endless compassion for other people (FG3).

Some participants described the struggle to maintain professional composure without breaking down at work. Several reported developing a sort of compassionate detachment as a way of coping:

It’s not that I feel like I have disconnected or I’m not empathetic with patients and sensitive to what they’re going through but I just don’t tend to let it too far in to my heart and that’s protective (II).

Several participants described cultivating a compassionate disposition and maintaining a positive outlook:

Save your energy for the things that matter, not looking too far into the future, not going what if, not what you’re missing out on but what you’ve got, look for the silver linings (FG4)

Many participants spoke about being present with patients and family at difficult points, referring to a higher purpose in caring for patients. They spoke of kind acts they could perform:

It is the smallest things when the loved one’s passed away, they [family] will remember… it can make them feel a bit better (FG3).

Some participants noted it was ‘getting harder’ to stay compassionate amidst a pandemic. Nearly all described system constraints and disruptions that impinged on their capacity to care for their patients in a compassionate way, particularly being resource and time-poor.

Discussion

The objective of this study was to explore healthcare workers’ experience of Schwartz Rounds on emotional aspects of care and practice. The principal findings were need for emotional processing, valuing guided reflection and realising common humanity. Participants in Schwartz Rounds generally found the experience to be beneficial and even cathartic. The preparation for and structure of the rounds lent a sense of psychological safety, in some cases, enabling participants to express deeper emotional content than intended.

The focus on healthcare professionals’ emotional concerns is a core component of Schwartz Rounds10 12 and there are clear benefits in enabling emotional expression and development of emotional literacy.11 13 18 The findings from this study support literature that identifies Schwartz Rounds as a unique counter cultural space to reflect on difficult emotions arising from healthcare work.8 11 18 Healthcare professionals acknowledged humane elements of their work27 and participation in the round highlighted acts of altruism, the importance of connection and expression of compassion in the healthcare setting.11 12 18 Many participants experienced difficult emotional dimensions related to their work and articulated a lack of opportunities to share feelings with those closest to them in the workplace.28

Given emotional recognition is an aspect of compassion for both self and others,29 attending Schwartz Rounds can be considered an act of self-compassion amidst the frenetic pace and high workload of public health services.1 Participants were able to acknowledge their own experiences of suffering as a common human experience. This balanced perspective taking is a mindful exercise that enhances interconnectedness and concern for others.29 Developing compassionate practice has physiological and psychological benefits.10 13 29 30 From an organisational perspective, Schwartz Rounds cultivate a culture of compassionate practice, which is increasingly accepted as an essential feature of sustaining quality healthcare.12 30

The team is a vital unit of healthcare, part of a wider system which powerfully influences collaboration between teams and patient’s experience of the system.1 Our study confirms benefits of a psychological secure space to enable healthcare professionals to share emotional perspectives.11 12 18 Many participants identified good and noble virtues in their colleagues,21 strong connections with their immediate teams, some alluding to the wider ‘family’ of healthcare professionals. Schwartz Rounds may engender a sense of community in bringing staff together from all parts of the organisation.11 31 The inclusion of those working in non-clinical roles—administrative, security, orderlies, cleaners—highlighted the value of their contributions to patients, staff and more widely to the healthcare system.16

The heart of public health services lies in emotional connection and investment.1 There is value in using narrative reflection in Schwartz Rounds to normalise, role model and collectively process emotional aspects of working in healthcare.12 13 This study further highlights the suboptimal attention paid to the emotional toll on staff in patient care. Healthcare staff find their work emotionally demanding and describe experiences of working in healthcare amidst conditions of increased workplace stress during the SARS-CoV-2 pandemic.2 7 Our study supports participation in Schwartz Rounds as an intervention,13 leading individuals to develop a more rounded understanding of their patients, the multidisciplinary environment and system complexity.8 9 12 13 Structured reflection lent meaning to participants as they acknowledged painful emotional aspects of caring and ways to sustain compassion in the healthcare environment.9 11 12 Responding to the emotional needs of healthcare workers takes place at multiple levels: individual self-compassion is a starting point to allow compassion to filter down to working with patients,32 33 reflection on team dynamics allows members to share responsibility for emotional concerns26 and developing a compassionate culture in healthcare organisations with active investment in measures to support the emotional well-being of staff.7 9 11 13 30

Strengths and limitations of the study

The strengths of this study were the inclusion of a diverse range of participants with varied experience of clinical, allied and technical specialties, working in frontline public health services. Participants in three of the four focus groups had close collegial relationships, forming rapport which facilitated open discussion. Member checking, cocoding of data and verification by an independent researcher are further strengths. There are several study limitations. We analysed the transcripts of the four focus groups and two individual interviews similarly using principles of thematic analysis as not all participants were able to attend the focus groups. The quotations are not attributed to individual participants and their role is not identified. This limits interpretation of themes across disciplines and deeper discussion of power differentials that exist within a healthcare hierarchy. Interactions within a group setting influence how and what participants say, and some may have been reticent or more vocal, thus potentially privileging the perspectives of senior staff who were present. We further acknowledge inherent relational dynamics in the focus groups that may have influenced the data collected and we did not analyse how group members engaged and interacted in the focus group setting. Limited participation from Māori and Pacific healthcare staff who were not well represented in the focus groups restricts comment on holistic practices within a cultural context.

Study implications and directions for future research

Our results indicate that organisations can take a more active role in implementing measures to protect staff welfare. The Schwartz Round is a compassion education intervention21 and one means to facilitate shared emotional processing.11–13 18 Due to the limited time allocated for a Schwartz Round, healthcare staff may particularly benefit from team-based psychological first aid that is tailored to their specialty. We recommend further research perspectives into the emotional benefits gained for staff through guided reflection and the potential for Schwartz Round linked psychological first aid.17 21 We support further exploration of enabling factors of Schwartz Rounds that promote authentic expression of emotions associated with difficult case material.11–13 There is strong evidence that Schwartz Rounds are beneficial.11 18 It would be useful to explore what aspects of the Schwartz Round contribute to preventing compassion fatigue and retaining the healthcare workforce.11 21 We endorse further qualitative research that gathers perspectives of particular disciplines and senior managerial staff to enable understanding of Schwartz Rounds as an intervention to sustain compassionate practice and how reflections can be applied to working in a healthcare system over time.

Conclusion

There is an organisational imperative to ensure that staff have opportunities to process intense emotions associated with healthcare work. Schwartz Rounds are one means to attend to the emotional welfare of healthcare staff, enabling them to gain different perspectives in the care of their patients and colleagues within system constraints.

Data availability statement

Data are available upon reasonable request. The authors report direct access to the study data. Access to transcripts of interviews with participants is ongoing and stored in accordance with University of Auckland Human Participants Ethics Committee guidelines. Data (deidentified transcripts and protocol) are available upon reasonable request and are available from the first author (ORCID number 0000-0002-7189-1272).

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants and was approved by University of Auckland Human Participants Ethics Committee (UAHPEC3503). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The authors gratefully acknowledge the participants involved in the research. Thank you to Lyn Lavery (LL) who independently analysed the data and to Paul Vroegop for his contributions to the project. Thanks to the executive leadership team at Te Whatu Ora Counties Manukau for their support of Schwartz Rounds.

References

Footnotes

  • Twitter @lilng1

  • Contributors LN and MY were responsible for the acquisition of data. LN, KS and JS were responsible for the analysis and interpretation of data. All authors contributed to the concept of the work, critically revising the content of the article and approving the final version. The authors are jointly responsible for the accuracy and integrity of the work. LN is the guarantor of the study.

  • Funding The researchers received funding from a Counties Manukau Health Tupu Award (Number 1326).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.