Moral distress, moral injury and hope
03 November 2025
Schwartz Rounds lead Rini Paul reflects on the impact of a decade of Rounds at an NHS trust in North London.
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I have been reflecting on and wanted to share some of my key learning after almost a decade as the Clinical Lead for the Integrated North Central London (NCL) Schwartz Rounds. I have learnt that opposites can be true and that there is no better space for holding those truths than in the Schwartz Rounds I have witnessed and facilitated since we began in 2016.
We were the first to bring Rounds into a Primary Care and Community setting in Islington, North London. Our physical and (post pandemic) virtual doors were open to all health, mental health, social care and voluntary sector staff (administrative, management and clinical) in this borough. Later, we extended our Rounds to all the five NCL boroughs, and to all Secondary Care staff reflecting just one of the many changes in structure in the systems we work in as Integrated Teams.
Schwartz Rounds are multidisciplinary reflective spaces, exactly one hour long, that focus on the impact of the emotional, social and/or ethical aspects of healthcare. Crucially, there is no pressure or need to problem solve. The space is held by a Clinical lead and Schwartz Round facilitator, who are trained in the UK by the Point of Care Foundation. Three to four panellists share a five-minute story on a theme or occasionally a team focussed on an aspect of patient care, and the Round is then opened to anyone who wishes to share their reactions to the stories they have heard, always ending with the panellists’ reflections again should they wish.
The facilitators hold the Round as a safe space in which people from any role within NCL can sit together with the stories, and all they bring. Schwartz Rounds are a place where we can be together, with all the emotions that may surface as we listen to the panellists’ stories. Sometimes there are moments of silence, these are ‘precious thinking time’; a few moments when we can let go of the continuing pressure to make judgements and to act. As an attendee in a Schwartz Round, you may choose to share a reflection or story of your own; or you may choose to sit and listen. In my experience once contributions to the conversation started flowing, they kept coming. We found that the Rounds broke down professional hierarchies, and we left each session feeling more connected, inspired, and united.
Schwartz Rounds are not for everyone, however, and quite rightly, they are never mandatory. At our first Round, a senior GP Partner resisted the Schwartz facilitator’s sensitive and skilful attempts to divert him from telling an experienced manager what he considered that he should have done in the situation described in his story. He continued to resist despite witnessing other participants who showed that they had grasped the concept of a Schwartz Round by sharing their own connections and reflections. It did not surprise me that he never returned.
But for many of us, Schwartz Rounds have provided a unique safe space where we could sit with the messiness and complexities of delivering healthcare. Alongside the many joyous and inspiring stories, we also heard stories of staff and patients feeling trapped, silenced, helpless and unable to make the decisions they would have wanted, violating our core values and resulting in moral distress.
Moral distress
Moral distress is a theme that has gained currency in healthcare in recent years. During the Covid pandemic the British Medical Association (BMA) surveyed its members and found that nearly half of those who responded were familiar with the concept. Once it was defined for them, three quarters recognised experiences of moral distress, and half identified experiences of moral injury at work.
Schwartz Rounds allow truths about cuts, austerity, targets and numbers to be described and named. We were among the first to hold rounds focused on discrimination. We have never shied away from exploring difficult themes – including burnout, belonging, bullying, moral distress and speaking up. Throughout, our focus has remained on amplifying diverse voices and fostering spaces that are safe, brave, and inclusive.
At our most recent round we heard stories of allowing patients and staff to live their own story, hope and our common humanity. We explored the conflicting and messy feelings once more, the vulnerability, the spark of hope and connection, and the relational impact of these spaces, often with colleagues we had never met in person.
Reflections of a Schwartz lead
One of the parts of the role I have loved the most – prepping panellists to share their stories – and of the absolute unconditional regard we held for one another as we listened.
Leading these Schwartz Rounds when they were held in person, I was continuously amazed that community staff would travel across the borough before returning to work, seemingly for a meal and a certificate. I have continued to be impressed at the commitment to the Rounds from colleagues across NCL month after month, since we have been virtual. In both cases they have sustained this commitment whether they contributed or not.
Leading Schwartz Rounds has been one of the biggest privileges of my clinical career. I am so grateful and thankful to all the steering group members (past and to date), Clinical co-leads, Schwartz Rounds facilitators and most importantly all our panellists/story tellers and audience members, for what I have learnt from you all, your wisdom, honesty, vulnerability, thoughtful questions, challenge, and space for warmth and tears. I am sitting with all of this, without the need to think about next steps or fixing things and feeling far more comfortable with this complexity of emotions then when I started back in 2016.
Since 2021, we have delivered 28 Rounds and reached nearly 500 unique participants. I’ll end with some of their words and a snapshot of the profound impact of our Primary Care Schwartz Rounds. This mirrors research demonstrating that Schwartz Rounds can reduce psychological distress and enhance compassion and appreciation among regular attendees.
“Really great! … I will definitely… recommend to colleagues. This sort of thing helps me to keep going in my clinical role.”
“It is a relief to hear colleagues’ experiences and feel like you are not alone with your thoughts and emotions.”
“This was my first session, and I have to say I didn’t quite know what to expect – it was the safest space I’ve been in. The stories told were personal and touching. The bravery of each speaker to openly talk about their stories, and the reflections from everyone, were emotive. We are all human, and that really resonated in everyone’s stories and comments.”
“The stories that were shared were very moving and really resonated with me. I found myself thinking about several patients, including one I met over 40 years ago as a student.”
Where else do these spaces exist for all staff to come together in this way?