Schwartz Rounds were set up by the Center for Compassionate Care in memory of Kenneth Schwartz, a medical attorney who developed terminal lung cancer. He noted that it was the moments of compassion shown by healthcare teams which meant the most to him during his treatment. The premise of Schwartz Rounds is that, in order to offer compassionate care to patients, healthcare teams need to be offered the same (Firth-Cozens and Cornwell, 2009). Noting the evidence in human-centred healthcare settings for Schwartz Rounds, transferability into the veterinary setting needs to be understood. As veterinary professionals experiencing compassion fatigue may have a reduced empathy for coworkers, this can result in reduced quality of care (Foote, 2000). Schwartz Rounds can provide a countercultural or third space for teams, which gives attendees a forum to reflect in a group setting.
Rounds usually last 1 hour, have two trained facilitators (who introduce and set the parameters of the Round) and two panellists, who start the reflective discussion by recounting experiences from their daily working lives. Audience members are invited to reflect as the stories stimulate similar memories or experiences – food is provided as part of the format of the Round (Martin, 2022).
Within a demanding healthcare environment, few opportunities exist to enhance relationships and communication among multidisciplinary teams (The Point of Care Foundation, 2015). However, Schwartz Rounds are a structured discussion forum in which whole teams come together to discuss the emotional and social impact of the work they do. This serves to normalise emotions and build compassion, which in turn can build resilience in human-centred health care professionals. By supporting the wellbeing of healthcare teams, the culture of an organisation can be affected (Maben et al, 2018). Schwartz Rounds provide an environment for exploration of all team members’ experiences, and therefore supports more collaborative relationships and loosens power hierarchies, resulting in improved patient safety.
Given that wellbeing scores are reducing in veterinary healthcare teams (Robinson et al, 2019), interventions proven to reduce psychological distress in human-centred healthcare could well improve wellbeing in veterinary teams. This article reports on the evaluation of Schwartz Rounds in a UK veterinary practice and is the first study to consider the transferability of Schwartz Rounds to the veterinary healthcare setting.
Veterinary healthcare: the impact of the work
In a recent RCVS survey of the veterinary profession, wellbeing scores had declined compared to 2014 and are lower than wellbeing scores from the national wellbeing survey, England, conducted in 2016. This suggests that the wellbeing of veterinary professionals is declining and is lower than that of the general population (Robinson et al, 2019).
Moses et al (2018) suggested that those working in veterinary practice often experienced moral distress, anxiety and were troubled by what they were asked to do within their roles, yet very few sought formal help; rather, most turned to informal support from colleagues and others. It is insufficient to expect workers to be responsible for seeking and managing the emotional burdens brought about by the nature of the work without organisational approaches to reduce the impact.
Human-centred healthcare
The evidence from human-centred healthcare can inform approaches in veterinary practice, as the difficulties and possible solutions are often very similar. Empirical studies have shown correlation between close integration of team members within human-centred healthcare teams and improved patient outcomes, organisations were also affected in terms of better morale, reduced burnout and staff turnover (Safran et al, 2006). Maben et al (2012) concluded that the work experiences of staff impacted directly on (human) patient care, suggesting that investment in staff wellbeing and culture is essential for the delivery of high-quality care. There is a growing body of evidence of a correlation between (human) patient safety culture and staff experience (Daugherty Biddison et al, 2016). As veterinary nurses place animal welfare and patient safety as a high priority in their work, paying attention to the factors for delivery of high-quality care is paramount.
In human-centred healthcare, the benefits of Schwartz Rounds are well evidenced. Lown and Manning (2010) reported that where Schwartz Rounds were used there was better teamwork, more appreciation of the roles of colleagues and that it enhanced the likelihood of staff members attending to the emotional aspects of care. Respondents also described changes in institutional culture. It is suggested that, with this in mind, Schwartz Rounds could affect the impact of emotional labour on our veterinary colleagues, in particular veterinary nurses, student nurses and veterinary care assistants who often account for a large part of the team.
The underlying premise for Schwartz Rounds is that compassion shown by healthcare workers improves clinical outcomes and that to provide compassionate care, team members must feel supported in their work. Schwartz Rounds provide a greater appreciation of the wider team, which relieves feelings of isolation, gives a sense of shared purpose and the honesty, openness and vulnerability shown by panellists allows others to see the person on a human level (Reed et al, 2015). It is posited that bringing more compassion into colleague and client interactions could serve to reduce miscommunication and complaints in veterinary work.
Whitehead et al (2021) suggested Schwartz Rounds allow human-centred health care workers to discuss topics that may be overlooked in normal day to day routine and their study demonstrated a reduction in immediate moral distress in some staff groups. Schwartz Rounds may enable processing of experiences, reduce professional and social isolation leading to better coping and better team cohesiveness, relieve work-related emotional distress and produce greater resilience through the mechanism of reflection (Maben et al, 2021). Maben et al (2018) previously concluded that the wellbeing of team members who regularly attended Schwartz Rounds over 8 months significantly improved, with the proportion of those with psychological distress reducing from 25% to 12%, while there was no significant change in the psychological wellbeing for those who did not attend Rounds over this period.
Methods
A UK veterinary practice with three branches began offering Schwartz Rounds to its team members in 2017, to promote wellbeing by offering a safe and contained reflective space. Standardised Point of Care Foundation feedback forms were used for 18 Rounds prior to the COVID-19 pandemic, which captured both quantitative and qualitative responses. A sign-in sheet was also collected for each Round. Data were compared against staff demographic data collected for the same period.
In this study, each Schwartz Round was offered at a different time during the working day, so that part time staff had access. The most frequent times were 09:30–10:30 and 14:00–15:00. The diary was scheduled around this protected hour and Rounds were always held at the same branch. Team members wishing to attend from other branches had travel time scheduled.
Data collection and analysis
The organisation gave permission for the anonymised demographic data (numbers and job role) of the team to be analysed to explore attendance at Schwartz Rounds. As this was a retrospective study, participant consent was not sought at the time of the Schwartz Rounds and therefore only quantitative data from the feedback forms have been used, not any qualitative data. The researcher was involved in facilitating the Schwartz Rounds; therefore, the data were independently evaluated by a professional colleague who is external to the practice and not associated with the administration of Schwartz Rounds.
Ethical considerations
The RCVS Ethics Review panel have authorised the study design and publication of this work.
Results
Attendance
Over 18 Rounds took place between December 2017 and February 2020, mean attendance was 30.11% of the team. The best attended round was Round 13, entitled ‘Why I come to work’ (50%) and the least attended was Round 15 ‘Behind closed doors’ (3.22%). Attendance numbers at Schwartz Rounds were relatively consistent, even as the team member numbers within the practice increased. Half of the Rounds analysed were above the mean attendance and the best attended Round (13) attracted 50% of the team. There are many known reasons for some fluctuation, such as shift patterns, workload and the fact that the practice has one branch which is an emergency and critical care hospital and therefore must always be staffed. In addition to this, attendance at Schwartz Rounds is optional. Thompson (2013) recognised the difficulties of releasing staff to attend Schwartz Rounds but argues that staff require time and facilities that improve (human) patient experience, therefore events that support wellbeing should be prioritised. This may also be true of veterinary colleagues.
Attendance by professional discipline
Over the course of this evaluation, 11.69% (n=12) of the vet team; 14.24% (n=16) of the registered veterinary nurse and paraprofessional team; 15.5% (n=7) of student veterinary nurses; 29.35% (n=5) of veterinary care assistants; 16.78% (n=11) of reception and administration staff and 18.52% (n=3) of managers attended Schwartz Rounds. The averages are based on feedback forms collected at the end of each round. On average there was a 63.66% response rate, and the question ‘to which professional group do you belong?’ was only answered on average 85.56% of the time. Table 1 shows the composition of the staff team by job role.
Table 1. Composition of the staff team by job role
| Round | Vet | Registered veterinary nurses and paraprofessionals | Student veterinary nurses | Veterinary care assistants | Reception and administrators | Managers | Total |
|---|---|---|---|---|---|---|---|
| 1 | 9 | 12 | 7 | 6 | 10 | 3 | 47 |
| 2 | 10 | 14 | 7 | 5 | 11 | 3 | 50 |
| 3 | 10 | 14 | 7 | 5 | 11 | 3 | 50 |
| 4 | 10 | 14 | 7 | 5 | 10 | 3 | 49 |
| 5 | 8 | 14 | 8 | 4 | 10 | 3 | 47 |
| 6 | 9 | 13 | 7 | 4 | 11 | 3 | 47 |
| 7 | 9 | 14 | 6 | 5 | 10 | 3 | 47 |
| 8 | 14 | 17 | 7 | 5 | 11 | 3 | 57 |
| 9 | 13 | 17 | 6 | 6 | 11 | 3 | 56 |
| 10 | 14 | 18 | 7 | 4 | 11 | 3 | 57 |
| 11 | 14 | 18 | 7 | 4 | 11 | 3 | 58 |
| 12 | 14 | 18 | 8 | 4 | 12 | 3 | 60 |
| 13 | 15 | 19 | 9 | 5 | 13 | 3 | 64 |
| 14 | 13 | 19 | 9 | 6 | 12 | 3 | 62 |
| 15 | 17 | 19 | 6 | 6 | 11 | 3 | 62 |
| 16 | 17 | 19 | 7 | 5 | 11 | 3 | 62 |
| 17 | 17 | 18 | 7 | 6 | 14 | 3 | 65 |
| 18 | 17 | 18 | 7 | 7 | 13 | 3 | 65 |
Evaluation
Table 2 shows the evaluation questions asked of participants of Schwartz Rounds, pulled from the Point of Care Foundation's standard feedback forms. Participants rated using a 5-point Likert scale. Over 90% of attendees found that the panellists’ stories were relevant to their own daily work and would help them work better with colleagues. Also, over 90% of attendees found the group discussion helpful and had a better understanding of their work. 91% planned to attend again and 94% would recommend Schwartz Rounds to colleagues.
Table 2. Evaluation questions asked of participants of Schwartz Rounds, pulled from the Point of Care Foundation's standard feedback forms. Participants rated using a 5-point Likert scale
| Statement | Agree somewhat or completely agree |
|---|---|
| The stories presented by the panel were relevant to my daily work | 95.40% |
| I gained insights that will help me meet the needs of my patients | 84.48% |
| Today's Round will help me work better with colleagues | 92.52% |
| The group discussion was helpful to me | 91.37% |
| I have a better understanding of how my colleagues feel about their work | 97.13% |
| I have a better understanding of how I feel about my work | 78.16% |
| I plan to attend Schwartz Rounds again | 91.38% |
| I would recommend Schwartz Rounds to colleagues | 94.15% |
During the time covered by the 18 Schwartz Rounds, the number of team members across the three sites fluctuated between 47 and 65. Occasionally, visitors attended the rounds and while they were not included in the demographic numbers, it has been impossible to remove their feedback data because of the anonymity of the feedback forms. These visitors were other veterinary professionals, head office workers, students, volunteers and people wishing to set up Rounds in their own organisation. Visitors were not introduced to avoid drawing attention to unfamiliar attendees. They participated as audience members and, as the Rounds are often multidisciplinary, the impact on the discussion was perceived to be minimal. The mean attendance was just over 30% which includes the whole staff team and visitors (a total of 5 visitors attended over the 18 Rounds, see Table 3 for Rounds affected). A core group of people, from the staff team attended on a regular basis with 9 team members attending 6‣10 Schwartz Rounds.
Table 3. The titles of the 18 Schwartz Rounds
| Round | Titles | Number of visitors |
|---|---|---|
| 1 | The patient I'll never forget | |
| 2 | Caught between the patient and the family | |
| 3 | Record not kept | |
| 4 | Above the call of duty | |
| 5 | Bad endings | |
| 6 | A client I'll never forget | |
| 7 | The time I made a difference | 1 |
| 8 | Digital panel | |
| 9 | Thank you | |
| 10 | Schwartz workshop | |
| 11 | What my patient taught me | |
| 12 | What keeps me awake at night | |
| 13 | Why I come to work | 2 |
| 14 | Working at night | 2 |
| 15 | Behind closed doors | |
| 16 | When communication breaks down | |
| 17 | Schwartz workshop | |
| 18 | I wasn't expecting that |
Of those attending, Table 2 shows the impact of Schwartz Rounds on individuals. Patients in this context relates to animal patients, not pet owners or human patients.
Discussion and recommendations
During a Schwartz Round, two panellists share a story about their daily lives and Table 3 gives the titles of the 18 Rounds used. These are often suggested by The Point of Care Foundation, but over time, the veterinary practice in this study has developed its own titles which speak to the needs of the team. Titles are used to encourage team members to bring stories and to focus the discussion. Some titles may resonate more than others and therefore could have an impact on attendance numbers. Over 95% either agreed somewhat or completely agreed that the panel stories were relevant to their own daily work. Panel stories are used as a springboard for group reflective discussion within the Schwartz Round.
Schwartz Rounds do not usually focus on current issues; rather, team members bring past stories when electing to speak on the panel and they are prepared thoroughly in advance by the facilitator team. Meeting as a group in this way creates resonance for other team members and they can connect elements of the speaker's story to their own practice. In contrast to an intervention such as private counselling, Schwartz Rounds encourage group reflection which can support normalising emotions in a high-pres-sure environment (George, 2016). Veterinary colleagues would benefit from less isolation in their roles and this type of meeting may impact feelings of impostor syndrome and perfectionist tendencies in this group.
Lown and Manning (2010) found that the more Rounds people attended, the greater the impact on that person's appreciation of colleagues’ roles and contributions, communication with colleagues and teamwork. Schwartz Rounds provide an opportunity for dialogue which has the potential to change institutional culture. In this study of veterinary professionals, 92% of the participants agreed somewhat or completely agreed that the Round will help them to work better with colleagues. On the statement ‘I have a better understanding of how my colleagues feel about their work’ 97% agreed somewhat or completely agreed. In total, 91% agreed somewhat or completely agreed that the group discussion was helpful and 78% agreed somewhat or completely agreed that they have a better understanding of their work. Schwartz Rounds were chosen as an intervention because they are inclusive of all job roles. It is reasonable to interpret attendance from all team roles as effectively reaching the whole practice community. Finally, over 90% planned to attend Schwartz Rounds again and would recommend them to colleagues. Reed et al (2015) stated that (in human-centred healthcare) Schwartz Rounds offer participants a safe environment to explore the human element of their work, enhance team working and promote a sense of purpose in a supportive environment. Maben et al (2021) suggests (in human-centred healthcare) that trained facilitators create trust, psychological safety and emotional containment which allow team members to be vulnerable. The safety provided by the facilitators and adherence to the Schwartz Round model results in self-disclosure which generates disclosure reciprocity. This transparency and catharsis improves team member wellbeing. This seems to be reflected in the data for veterinary Schwartz Rounds.
Study limitations
There are limitations associated with the data, related to the retrospective nature of the study. To provide participant anonymity and because of the lack of prior consent, qualitative data cannot be included in the analysis.
The design of the feedback form is such that in 63% of responses some questions were missed by participants; therefore, it is difficult to generalise the data. In addition, these self-reported behaviours cannot be assumed to correlate with actual behaviours.
It must be noted that the feedback forms have been handed back to the author, who is a leader in the organisation, and the author is aware of the potential for bias created by this action.
This study was undertaken in one practice group, therefore the transferability to others is not certain, however, the results are encouraging.
Recommendations for further study
A qualitative study would be most insightful to collect thoughts and attitudes towards Schwartz Rounds and this is recommended as a next step. Within this study, 84% of attendees agreed somewhat or completely agreed with the statement ‘I have gained insights that will help me meet the needs of my patients’. The nature of the question is aimed at human patients, and this is extrapolated to animal patients; however, it would be interesting to study whether these insights extend to the pet owner and the impact on client satisfaction. A study by Gibson et al (2022) concluded that client complaints present a threat to the mental health of veterinary practitioners, workforce sustainability and have implications for patient safety. There is some evidence in human-centred healthcare that compassionate care builds patient trust (Kim et al, 2004; Weiss et al, 2017). It would be valuable to study whether this would be true of veterinary clients and therefore the impact on complaints and patient outcomes.
As one of the main benefits of Schwartz Rounds is their multidisciplinary nature, it is encouraging to see attendance across a broad range of team roles. With the exception of those in a management role, these data do not disaggregate in terms of seniority/years qualified (or in the profession). We must attract senior and junior team members from a range of roles to enable the ‘Aha!’ moments which so often happen within a Round, such as when someone states ‘I didn't know it was like that for you’. This leads to powerful Rounds as attendees understand their colleagues’ world or experience (Maben et al, 2021).
Future studies should explore the influence of age, gender, race, ethnicity, years of experience in the profession and years in position in relation to attendance at Schwartz Rounds, as no data were collected on the diversity of participants. This would help to ensure that Schwartz Rounds are inclusive and therefore able to affect practice culture and promote equity among team members.
The management team in this veterinary practice are committed to encouraging attendance at Schwartz Rounds, and it would be interesting to study team members’ perceived barriers to attending to see how this can be improved. Schwartz Rounds are not mandatory and team members may leave during a Round. Maben et al (2021) noted that staff wellbeing strategies require a multi-pronged approach and Schwartz Rounds may not work for everyone. Interventions for wellbeing that target prevention and treatment of ill health, individuals, teams and whole organisations should be considered.
This study was undertaken prior to the COVID-19 pandemic, and subsequently Schwartz Rounds ceased and then moved online. Data from post COVID-19 in-person Rounds will be an interesting reflection on the need for this space in the aftermath of a pandemic to support the wellbeing of veterinary colleagues.
Conclusions
It is reasonable to conclude that providing a reflective space for all team members to come together and discuss the emotional and social aspects of their work can support colleagues’ wellbeing at work. One method of doing this is Schwartz Rounds. This study has shown, in a small group of participants, that there are benefits to this way of meeting. The results are encouraging, however the impact upon patient care and client satisfaction is as yet unknown.
Schwartz Rounds
Schwartz Rounds are run under licence from The Point of Care Foundation for UK and Ireland. The Schwartz Rounds programme is provided in cooperation with The Schwartz Center for Compassionate Healthcare and with the support of The Point of Care Foundation.
- www.theschwartzcenter.org
- www.pointofcarefoundation.org.uk
KEY POINTS
- Schwartz Rounds attend to the emotional impact of care giving.
- Over 90% of participants found the group discussion helpful.
- There is evidence to support the introduction of Schwartz Rounds as a reflective space for veterinary colleagues.
- Collection of qualitative data is recommended to further understand the impact of Schwartz Rounds.