Schwartz Rounds: Origins, early development and implementation in the US and UK Schwartz community conference - London Point of Care Foundation Thursday 27 October 2016 Dr Mary Leamy Professor Jill Maben
Please be aware, these are emerging findings and have not been under peer review.
Aims a) to identify the intervention’s origins and initial development in USA; b) to explore the cross-cultural transfer of Schwartz Rounds; and c) to explore implementation issues of fidelity and adaptation.
Methods Key stakeholder interviews • Individual interviews with Marjorie Stanzler, Dr. Thomas Lynch, Dr. Beth Lown (N=3). • Group interview with trainers, facilitators and clinical leads from Schwartz Center for Compassionate Care (SCCC) and surrounding hospitals, USA (N=2); • Individual interviews with PoCF staff and facilitators and clinical leads from pilot sites, UK (N=6). Ethnographic observations • Schwartz Rounds, USA (N=2) • Debriefing with SCCC Regional Advisor, USA (N=1) • Schwartz Training, UK (N=2) [Also informed by N=43 observations of Rounds, N=30 Steering group meetings, N=28 panel preparation meetings and N=176 interviews, UK]
Origins of Schwartz Rounds: Guiding principles 1. Compassionate care can be taught “ I believe you can teach compassion. I believe you can teach people to be more connected with their patients. It's just like I believe you can teach people how to read an ECG scan.” ( Thomas Lynch)
Origins of Schwartz Rounds: Guiding principles 2. Equity - Rounds are for everyone “ We also knew that everybody touched the patient, because of Ken ’ s story. He talked about the technician that wheeled him down to the CT scan, that person showing compassion, so we knew that we wanted to include everybody in the hospital setting, this wasn ’t just for doctors” (Thomas Lynch) “ Put everybody on an equal playing field, some of the best things of Schwartz Rounds, were the team aspects, where nurses realise that doctors struggle with the same thing, and doctors realise nurses struggle with the same thing. I think that's one of the things about Schwartz Rounds that's been so important in their growth and success ” (Marjorie Stanzler).
Origins of Schwartz Rounds: Guiding principles 3. Acceptability - Crucial for doctors to attend “ I knew in the very beginning that I had to make them as medical as possible, so people would not see them as being soft, okay. Now maybe in England that's not an issue, but in the US, doctors want to be tough, you know, macho, and so in the first couple of Schwartz Rounds, we actually presented X-rays and we talked about the case, the medical part of it first, before we talked about the soft stuff. Eventually we got away from presenting the X-rays and the medical stuff, and just did the soft stuff, because that was the fun part .” (Thomas Lynch)
Origins of Schwartz Rounds: Guiding principles 4. Practicality - Structured format and focused guidance “We came up with this format where there’d be an identified topic for discussion and there’d be a panel of ideally three people that were involved in the case, and they would very briefly present what the experience was like, and that one of them would summarise the clinical information very briefly ….. we struggled a lot at the beginning and ….we really had to work hard … to get people to summarise that briefly, because most of it didn’t even matter, and then really talk about the issue at hand.” (Marjorie Stanzler). “ Somehow we came up with the, you know, the whole form: the facilitator, the audience participation, emphasising to people this was not a problem-solving session… we have to tell people again and again the purpose of the Rounds.” (Thomas Lynch)
Origins of Schwartz Rounds: Guiding principles 5. Co-facilitation: Role modelling “ Being willing to share your own vulnerability is enormously important as a moderator [referring to himself, i.e. medical lead role], okay. Being willing to talk about how you made a mistake or you were vulnerable, or you didn't provide, didn't connect with the patient, or you did something wrong, or sharing experiences didn't go well, will make everyone else feel so much more comfortable .” (Thomas Lynch)
Origins of Schwartz Rounds: Guiding principles 6. Safe and non-judgemental space “ You have to validate their opinion and realise that you're creating a safe environment where if somebody wants to say something that's insane, that's okay, so being non- judgmental, not allowing anyone to get bullied, is a huge part of Schwartz rounds.” (Thomas Lynch).
UK/US S co concep ceptua tuali lisation sation of Sc Schwar wartz tz Rounds ds US Conceptualisation of UK Conceptualisation of Rounds Rounds Language: Language: Panellists’ contributions not Panelists’ contributions framed as described as story-tellers being ‘Story - tellers’. Focus: Focus: Explicit educational focus Impromptu educational element Format: Format: Fluid structure (e.g. integration of Structured / tight control over panel and audience, telephone format and timings of Rounds rounds) stages (conceptualised as having 6 different stages). Type: Type: Case-based, theme-based and Case-based, theme-based patient (presenter)-based Rounds Rounds, but only a few patient (presenter)-based Rounds.
UK/US implementation differences US Conceptualisation of Rounds UK Conceptualisation of Rounds Facilitator: Facilitator: Emphasis on psychological & Not restricted to those with psychological psychotherapeutic knowledge and skills and psychotherapeutic knowledge and skills Clinical lead: Clinical lead: Greater responsibilities for finding and Responsibility for finding and preparing preparing panelists with medical lead panelists shared between facilitators, steering group and clinical lead Panel preparation: Panel preparation: Face to face meetings, but can include Mainly face to face meetings . Use of email preparation entirely via email and /telephone support as follow up. telephone. Manualisation, initial training, resources: Manualisation, initial training, resources: Initially none Handbook, training Online resources & webinars Online resources and webinars Mentor network: Mentor network: 5 regional advisors to cover USA (2015) 19 mentors to cover UK (2016)
Summary Transfer of Rounds from USA and UK settings has lead to some UK adaptations and innovations: • Notably in training and mentorship of facilitators and clinical leads • Extent to which panelists receive prior support to tell their stories publically • Notably now framed as staff wellbeing intervention in UK Connections between SCCC and PoCF has also led to changes in USA implementation of Rounds: • in the ways SCCC now trains, mentors and supports sites and facilitators, following the UK example • Some USA adaptations and innovations have not (yet) been taken up, e.g. telephonic Rounds or Rounds where there is more panelist & audience integration. • Some UK sites discovering ways to scale down Rounds and deliver them as ‘pop up’ Rounds, to address the needs of staff who cannot easily attend Rounds.
Thank you Dr Mary Leamy mary.leamy@kcl.ac.uk Professor Jill Maben jill.maben@kcl.ac.uk Acknowledgments This presentation is part of the findings from an independent research funded by the National Institute for Health Research (HS&DR - Project: 13/07/49). The views expressed in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, MRC, CCF, NETSCC, the HS&DR programme or the Department of Health
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