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Schwartz Rounds: facilitating staff conversations in the Irish healthcare system

Dr Vivienne Brady and Dr Margarita Corry; Dr Maureen Flynn School of Nursing and Midwifery, University of Dublin, Trinity College Dublin; National Quality Improvement Team, Health Service Executive, Ireland 09 October 2019

A new evaluation of Schwartz Rounds in Ireland studied the impact of Rounds in different settings within the Irish Health Service. Two of the report’s authors, and a member of the National Quality Improvement Team at the Irish Health Service Executive, share some of the learnings from the evaluation.

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In 2015, the Irish Health Service Executive (HSE) National Quality Improvement Team engaged the Point of Care Foundation to licence, train and mentor staff in two test of concept sites: one palliative inpatient and community care setting, and one large acute university hospital. This arrangement was extended in 2017 to support 30 teams who wanted to establish Schwartz Rounds. Since the process began, 25 healthcare organisations in Ireland have signed a service level agreement with the Point of Care Foundation. In the meantime, the National Quality Improvement Team (HSE) commissioned an external evaluation by a research team at Trinity College Dublin, to establish whether Schwartz Rounds are fit for purpose in the Irish Health Service. This evaluation took place in the two test of concept sites in 2017/2018.

The report of this evaluation was launched at a ‘Launch and Learn’ event on 27th May 2019 at Dr. Steeven’s hospital, Dublin, hosted by the HSE. The audience included clinical leads, Schwartz Rounds facilitators, administrative staff and steering group members, other leaders and interested parties from across the health systems and the National Quality Improvement Team. At the launch, the HSE Director General, Mr Paul Reid, stated that the specific findings of the report – that Schwartz Rounds break down barriers and reduce hierarchy – will potentially change the conversation in the Irish healthcare system. 

The specific findings of the report – that Schwartz Rounds break down barriers and reduce hierarchy – will potentially change the conversation in the Irish healthcare system.
Paul Reid, HSE Director General

Findings

The research findings reflect the positive adoption of Schwartz Rounds at the organisational leadership level. While individual responses to Schwartz Rounds were mixed, there was explicit personal and professional impact for those participants who engaged fully with Schwartz Rounds, with reports of increased motivation in work, and opportunities for reflection and for learning.

In keeping with UK research (Maben et al. 2018), participants in the Irish context reported Rounds to be of benefit in terms of working with colleagues and gaining insight into how co-workers care for patients. Areas consistently highlighted in the qualitative data were greater insight into the self and others, the breaking down of barriers and a levelling of hierarchical structure. 

Participants of this evaluation indicated that insight into their colleagues’ experiences enabled them to empathise with their co-workers. This, along with the reported recognition of the role of others and shared connectedness, can impact on interpersonal relationships and relieve some of the stresses experienced in attending to the emotional needs of patients.

The sharing of stories characteristic of the Schwartz Round ethos was also found to be beneficial, for junior staff particularly, as this helped them to normalise their perceptions of inadequacy with the knowledge that there were others, who, after years of practice, continue to find the emotional aspects of caring challenging. This also offered a reminder of the availability and willingness of colleagues to extend support when needed. 

Participants in the evaluation had difficulty extracting explicit outcomes or a tangible workplace culture change at organisational level. This may be due to the timing of the evaluation in the relatively early stages of implementation in the Irish setting. Individual responses, however, reflect tacit changes, which may impact upon long term organisational culture change.

Practical considerations

Appropriate planning and implementation in response to organisation size and numbers of staff is an important aspect of successful reach and access to information, particularly relevant to a larger site. Additionally, the evaluation findings indicate that participants need to be clear that Schwartz Rounds are not a problem-solving forum, but an opportunity to promote a safe space for all staff to discuss and reflect on the emotional impacts they experience within their roles and functions in healthcare. 

Some dissatisfaction with Schwartz Rounds in the Irish context appears to be attributable to practical considerations, such as the frequency of Rounds, numbers of staff in the organisation and reported pressure to participate as a consequence of a small pool of willing participants. Merging smaller organisations for Schwartz Rounds presents practical issues, not least the prospect of travel commitments for staff. There are also challenges to managing large numbers of personnel; the physical environment for Schwartz Rounds requires a room to accommodate participants, in addition to measures necessary to improve the general audibility of speakers. 

One of the key learnings of the research was the need for expert help to establish support structures for facilitators and steering committees. The Point of Care Foundation has responded to this need through identifying a nationally based support person for mentors across the adopting sites in Ireland. 

The report concluded that the philosophy of Schwartz Rounds is consistent with the Health Service Executive’s (HSE) strategic drive for quality and safe health care. The HSE are using the evaluation report and its 20 key learning points to inform how Schwartz Rounds may be rolled out and sustained across Ireland. 

Access the full report