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Talking helps nurses cope with trauma

With research showing Schwartz rounds improve psychological well-being, cancer nurses explain how they benefit from the forums

With research showing Schwartz rounds improve psychological well-being, cancer nurses explain how they benefit from the forums

  • Schwartz rounds help staff share emotional and psychological impact of their work
  • Confidential sessions allow staff to talk about difficult experiences
  • Panel members share their stories and facilitator guides discussion with audience

A Schwartz round discussion Picture: The Christie Hospital

When clinical liaison nurse Charlene Jones was faced with a 22-year-old patient who refused potentially life-saving cancer treatment, she felt upset and angry.

‘I work with 16 to 25 year olds and am well-used to non-compliance,’ says Ms Jones, a Teenage Cancer Trust clinical liaison nurse at the Christie Hospital in Manchester.

‘But this was the first time I had experienced out-and-out refusal of treatment. It just seemed crazy and incredibly upsetting to know we could have helped. I felt I had failed.’

185

NHS organisations use Schwartz rounds

(Source: Point of Care Foundation)

‘It felt like a battle’

Her patient refused surgery, radiotherapy and chemotherapy and instead opted for privately funded alternative medicine. She later died.

‘As a nurse you want to support patients, even if you can’t solve everything, but this felt like a battle.’

After the patient’s death Ms Jones says she questioned her own practice and repeatedly asked herself if she had done enough. ‘It was difficult and I buried the emotions.’

‘I was apprehensive about opening up’

Six months later Ms Jones was asked by her manager to speak about the experience to other staff members as part of a Schwartz rounds session on refusing care.

The rounds were introduced to the UK in 2009 to support staff to deliver compassionate care by helping them reflect on their work and share the emotional, psychological and social impacts of working in healthcare.

The confidential sessions, typically held monthly, allow clinical and non-clinical staff from across an organisation to talk about difficult experiences such as patients refusing treatment and the emotional effect this has on them.

Each session lasts for an hour and is chaired by a trained facilitator. Three to four panel members from various disciplines share their stories, with the facilitator guiding a discussion with the audience.

Ms Jones, who had been to just one session previously, was joined on the panel by two consultants.

‘I was apprehensive about opening up and being vulnerable in front of so many people. I knew the format, but the experience seemed so fresh in my mind.’

‘You are in the eye of the storm’

Before the session Ms Jones wrote a draft of her remarks and went through it with the facilitator.

She says having time to think about the experience and reliving it with a supportive facilitator before the round was cathartic.

37

UK hospices use Schwartz rounds

(Source: Point of Care Foundation)

‘I felt safe going through the event. When you are in the eye of the storm it is difficult to step back and think about things logically.

The right to make bad decisions

‘Preparing for the panel made me realise that the patient’s refusal wasn’t about my personal practice.

‘It was her decision, and people have the right to make what we as professionals feel are bad decisions.’

As well as learning not to take the incident personally, the nurse says it has changed her approach when young people talk about refusing treatment.

‘Thinking I’d failed as a nurse’

‘I feel I now have an improved understanding of their treatment concerns. If I had not done the Schwartz rounds I would have struggled more with thinking I’d failed as a nurse.’

She says staff in similar situations have contacted her since she took part in the rounds and she feels more able to support them too.

The first national evaluation of Schwartz rounds in the UK concluded that they offer ‘a unique counter-cultural space providing time in which trust is built and emotional safety and containment is offered’.

Benefits and challenges of the sessions

Benefits

  • A unique organisation-wide intervention open to all
  • A safe, reflective space for staff to make sense of the challenges of their work
  • A space where staff experiences are centre stage and emotional openness and honesty are prized
  • Attendance linked to improved psychological well-being

Challenges

  • Rounds are resourced and run differently, with varying levels of trust and safety created
  • Front-line and ward staff struggle to attend
  • How panellists tell their stories and how much they share differs
  • Resources are required to sustain rounds.

Source: National Institute for Health Research

As with Ms Jones, the three-year research project found panellists experienced ‘catharsis and some release of burden’ through taking time to think about their experience and speaking about it to others.

For audience members, the research concludes sessions are ‘interesting and engaging’ and a source of support.

It found staff valued the opportunity to reflect and mentally process work challenges and learn more about colleagues and their management of difficult patient cases.


Jill Maben

Researchers also found that among staff who regularly attended rounds as audience members, the proportion with poor psychological well-being halved – down from 25% to 12%.

Conversely, there was little change in staff who did not attend rounds, with one third of them reporting poor psychological well-being.

‘Staff show their human and vulnerable side’

University of Surrey professor of health services research and nursing Jill Maben led the research, which was funded by the National Institute for Health Research.

Professor Maben, a nurse and expert on supporting staff to provide the best possible patient care, says: ‘Our study found that when staff show their human and vulnerable side it breaks down barriers and creates a level playing field for all staff.

‘Attendance at rounds also creates recognition of shared experiences and feelings, providing greater insights into patient, carer and staff behaviours, increasing empathy, compassion and tolerance and reducing feelings of isolation.’

Researchers compared literature reviews on rounds with 11 other similar interventions such as action learning sets.

50%

of acute trusts in England adopted the rounds by July 2015

(Source: NIHR research)

They also interviewed 48 staff running rounds across 46 organisations, surveyed 500 staff in ten organisations attending rounds, interviewed a further 177 staff from nine organisations who were either facilitators or panellists, and audience members who listened and contributed in the debates.

Greater self-compassion

Researchers also observed preparation meetings, the rounds themselves and steering group meetings.

They identified a number of organisational ‘ripple effects’ as a result of rounds, including changes to protocols and the setting up of new support groups.

Participants noted a number of changes in themselves, such as greater self-compassion, becoming more reflective, and being more open to emotional aspects of their work and to learning from others.

The man who started Schwartz rounds

Schwartz rounds were inspired by healthcare lawyer Kenneth Schwartz, who while terminally ill with lung cancer wrote about his experiences in the US newspaper the Boston Globe in 1995. He noted how ‘small acts of kindness made the unbearable more bearable’.

He saw that some staff were able to be compassionate while others were not, and how the same staff member could be compassionate one day and not the next. Before his death, he set up the US-based Schwartz Center for Compassionate Healthcare.

The London-based Point of Care Foundation is licensed by the center to provide support and training to organisations wanting to run Schwartz rounds in the UK.

In May, Alyson Foyle, a matron at the Royal Marsden NHS Foundation Trust in London, was a panel member during a session on mental health.

She had taken time off work following a mental health episode brought on by stress, anxiety and compassion fatigue – secondary distress arising from taking care of people.

The nurse was joined on the panel by a medical registrar, a pharmacist and a finance team member with similar experiences.

‘A special hour in an otherwise chaotic day’

She told the 100 or so audience members about her mental health episode, her recovery and subsequent promotion to matron.

‘The round gave me the platform to turn what was a negative experience at the time into a positive one now.

‘The feeling of achievement and sharing with people that you can – with help and support – come back from something like this is a wonderful feeling,’ she says.

The nurse, who encourages other staff to attend rounds, describes them as ‘a special hour in an otherwise chaotic day’.

Working better with colleagues

Although nearly half of all NHS acute trusts in England adopted the rounds by July 2015, research also found that they are being implemented in various ways.


Anne-Marie Raftery

Anna-Marie Stevens is the lead nurse for Schwartz rounds at the Royal Marsden, where rounds were introduced four years ago.

An evaluation of the trust’s own data found 88% of participants believe sessions helped them work better with colleagues.

Representation across all staff groups

But Dr Stevens, a nurse consultant, agrees several factors are needed to ensure the rounds’ success.

‘Support from the chief nurse, the chief executive, and the medical director is important, along with good themes that ensure equity for panel representation across all staff groups.

‘Ambassadors to support Schwartz rounds in the organization helps, as does a group to help approach potential panel members,’ advises Dr Stevens.

‘They see each other in a new light’

Anne-Marie Raftery, a Macmillan cancer nurse specialist in palliative care at the Christie, is a trained Schwartz facilitator and has led rounds at her trust since their inception in 2015.

She says it can take considerable time to plan rounds and identify and support panelists to tell their story. But she says the results are more than worth the effort.

‘The coming together of staff, the meeting of people who would not normally meet, the appreciation of other people’s roles and the support they give each other is really quite something.

It is as if they take off their work badges and see each other in a new light.’


Tamsin Newton Snow is a health writer

Find out more

A realist informed mixed methods evaluation of Schwartz Center Rounds in England (National Institute for Health Research) 

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