Schwartz Centre Rounds: a new initiative in the undergraduate curriculum-what do medical students think?

How Does a Group Reflection Intervention (Schwartz Rounds) Work within Healthcare Undergraduate Settings? A Realist Review

Introduction

Schwartz Rounds ("Rounds") are a confidential group reflection forum, increasingly adopted to support pre-registration healthcare students. This realist review aims to understand what the available literature and key informant interviews can tell us about Rounds in this setting, asking what works, for whom, in what circumstances, and why?

Methods

Published literature discussing Rounds in undergraduate settings were analysed using realist methods to describe how, for whom and in which contexts Rounds work. Four key informants were interviewed using realist methods, to further develop, test and refine a programme theory of Rounds in undergraduate settings.

Results

We identified five core features and five contextual adaptations.Core: Rounds provide a reflective space to discuss emotional challenges; Rounds promote an open and humanised professional culture; Rounds offer role-modelling of vulnerability, enabling interpersonal connectedness; Rounds are impactful when focused on emotional and relational elements; Rounds offer reflective insights from a wide range of perspectives.Contextual adaptations: Rounds allow reflection to be more engaging for students when they are non-mandatory; perceptions of safety within a Round varies based on multiple factors; adapting timing and themes to students' changing needs may improve engagement; resonance with stories is affected by clinical experience levels; online adaptation can increase reach but may risk psychological safety.

Discussion

Schwartz Rounds are a unique intervention that can support healthcare students through their pre-registration education. The five "core" and five "contextual adaptation" features presented identify important considerations for organisations implementing Rounds for their undergraduates.

How to organise and run Schwartz rounds

RATIONALE AND KEY POINTS

Schwartz rounds are a group-based model of reflective practice originally designed to assist medical staff to develop more compassion in their care. The aim of Schwartz rounds is to help healthcare professionals such as nurses 'reconnect' with why they first entered the caring profession. • Schwartz rounds are designed to assist multidisciplinary healthcare professionals with the emotional, social and ethical aspects of caregiving. • Schwartz rounds can also be used to support resilience training and boost workforce morale. • The use of Schwartz rounds can assist nurses to understand the moral challenges they may encounter while caring for patients. REFLECTIVE ACTIVITY: 'How to' articles can help to update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of: • How this article might help you organise Schwartz rounds in your clinical area. • How you could use this information to educate your colleagues about Schwartz rounds.

Early introduction of the multi-disciplinary team through student Schwartz Rounds: a mixed methodology study

BACKGROUND

Medical education has changed continually throughout the covid-19 pandemic, creating additional stress for medical students. Personal reflection can empower an individual to adapt to new challenges, and reflection has gradually become incorporated into medical student training. Schwartz Rounds (SR) offer a compassionate group reflective forum for healthcare staff. SRs have been extensively introduced throughout the NHS, however medical student rounds are yet to be widely adopted. Entirely unresearched is how the multi-disciplinary team impacts a medical student SR. This study aims to compare medical student experience of a single-discipline and a multi-discipline SR using mixed methodology.

METHODS

Two virtual SRs were run at an NHS district general hospital, using the existing structure of the Trust's rounds. The first round included only medical students on placement at the hospital, whereas the second round also involved other student health disciplines. Following each round Likert scale questionnaires were collected, and focus groups were held with a small number of participants. Quantitative analysis used median averages as well direct comparison of scores for each round. Qualitative data from the focus groups underwent thematic analysis.

RESULTS

The quantitative data showed a positive response to both styles of student SRs, with over 87% of participants at both rounds stating they intended to attend further rounds. Direct comparison between the two rounds showed higher feedback scores for the single-discipline round. Qualitative analysis showed strong student interest in further group reflection, noting the value of SRs in improving workplace culture and inter-professional relationships. The analysis also highlighted frustrations with the existing SR structure, namely large group sizes and scripted panellists.

CONCLUSIONS

Both data sets showed a strong positive response to SRs, and a desire to attend again. There is some evidence to suggest the addition of multiple student disciplines at SRs impaired medical student reflection. Changes to the format of the round could result in even greater success in student rounds.

Schwartz Rounds for Staff in an Australian Tertiary Hospital: Protocol for a Pilot Uncontrolled Trial (Preprint)

Background

Schwartz Rounds are a unique, organization-wide interdisciplinary intervention aimed at enhancing staff well-being, compassionate care, teamwork, and organizational culture in health care settings. They provide a safe space wherein both clinical and nonclinical health staff can connect and share their experiences about the social and emotional aspects of health care.

Objective

Although Schwartz Rounds have been assessed and widely implemented in the United States and United Kingdom, they are yet to be formally evaluated in Australian health care settings. The purpose of this study is to evaluate the feasibility and impact of Schwartz Rounds on staff well-being, compassionate care, and organizational culture, in a tertiary metropolitan hospital in Brisbane, Australia.

Methods

This mixed methods repeated measures pilot study will recruit 24 participants in 2 groups from 2 departments, the intensive care unit and the gastroenterology department. Participants from each group will take part in 3 unit-based Schwartz Rounds. Primary outcomes will include the study and intervention feasibility measures, while secondary outcomes will include scores on the Maslach Burnout Inventory–Human Services Survey, the Schwartz Centre Compassionate Care Scale, and the Culture of Care Barometer. Primary and secondary outcomes will be collected at baseline, after the Rounds, and 3-month follow-up. Two focus groups will be held approximately 2 months after completion of the Schwartz Rounds. Descriptive statistics, paired t tests, chi-square tests, and analysis of variance will be used to compare quantitative data across time points and groups. Qualitative data from focus groups and free-text survey questions will be analyzed using an inductive thematic analysis approach.

Results

The study was approved by the Mater Hospital Human Research Ethics Committee (reference number: HREC/MML/71868) and recruitment commenced in July 2021; study completion is anticipated by May 2022.

Conclusions

The study will contribute to the assessment of feasibility and preliminary efficacy of the Schwartz Rounds in a tertiary Australian hospital during the COVID-19 pandemic.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12621001473853; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382769&isReview=true

International Registered Report Identifier (IRRID)

DERR1-10.2196/35083

Realist evaluation of Schwartz rounds® for enhancing the delivery of compassionate healthcare: understanding how they work, for whom, and in what contexts

Background

Healthcare work is known to be stressful and challenging, and there are recognised links between the psychological health of staff and high-quality patient care. Schwartz Center Rounds® (Rounds) were developed to support healthcare staff to re-connect with their values through peer reflection, and to promote more compassionate patient care. Research to date has focussed on self-report surveys that measure satisfaction with Rounds but provide little analysis of how Rounds ‘work’ to produce their reported outcomes, how differing contexts may impact on this, nor make explicit the underlying theories in the conceptualisation and implementation of Rounds.

Methods

Realist evaluation methods aimed to identify how Rounds work, for whom and in what contexts to deliver outcomes. We interviewed 97 key informants: mentors, facilitators, panellists and steering group members, using framework analysis to organise and analyse our data using realist logic. We identified mechanisms by which Rounds lead to outcomes, and contextual factors that impacted on this relationship, using formal theory to explain these findings.

Results

Four stages of Rounds were identified. We describe how, why and for whom Schwartz Rounds work through the relationships between nine partial programme theories. These include: trust safety and containment; group interaction; counter-cultural/3rd space for staff; self-disclosure; story-telling; role modelling vulnerability; contextualising patients and staff; shining a spotlight on hidden stories and roles; and reflection and resonance. There was variability in the way Rounds were run across organisations. Attendance for some staff was difficult. Rounds is likely to be a ‘slow intervention’ the impact of which develops over time. We identified the conditions needed for Rounds to work optimally. These contextual factors influence the intensity and therefore degree to which the key ingredients of Rounds (mechanisms) are activated along a continuum, to produce outcomes. Outcomes included: greater tolerance, empathy and compassion for self and others; increased honesty, openness, and resilience; improved teamwork and organisational change.

Conclusions

Where optimally implemented, Rounds provide staff with a safe, reflective and confidential space to talk and support one another, the consequences of which include increased empathy and compassion for colleagues and patients, and positive changes to practice.

What Is the State of Compassion Education? A Systematic Review of Compassion Training in Health Care

PURPOSE

To investigate the current state and quality of compassion education interventions offered to health care providers during training or practice, determine how the components of each education intervention map onto the domains of an empirically based clinical model of compassion, and identify the most common approaches to compassion education.

METHOD

The MEDLINE, Embase, CINAHL Plus with Full Text, Sociological Abstracts, Web of Science, ERIC, and Education Research Complete databases were searched from inception to March 2020 in this systematic review. Studies that evaluated a compassion education intervention for health care providers or those in training to enhance compassion toward patients and/or families were included. A narrative synthesis of the included studies was performed. The components of each intervention were mapped onto the domains of compassion described in the Patient Compassion Model.

RESULTS

One hundred eight peer-reviewed publications describing 103 interventions were included. Modalities ranged from establishing curricula and interventions in clinical settings to programs that used humanities-based reflective practices, clinical simulation, role modeling, and contemplative practices, with many education interventions adopting a multimodal approach. Most interventions mapped to the virtuous response domain of the Patient Compassion Model; very few mapped to the other domains of this model.

CONCLUSIONS

Most interventions were limited as they focused on a single domain of compassion; did not adequately define compassion; were assessed exclusively by self-report; were devoid of a comparator/control group; and did not evaluate retention, sustainability, and translation to clinical practice over time. The authors suggest that compassion education interventions be grounded in an empirically based definition of compassion; use a competency-based approach; employ multimodal teaching methods that address the requisite attitudes, skills, behaviors, and knowledge within the multiple domains of compassion; evaluate learning over time; and incorporate patient, preceptor, and peer evaluations.

The burden they bear: A scoping review of physician empathy in the intensive care unit

PURPOSE

Research shows that physician empathy can improve patients' reporting of symptoms, participation in care, compliance, and satisfaction; however, success in harnessing these advantages in the ICU hinges on a myriad of contextual factors. This study describes the current state of knowledge about intensivists' empathy.

METHODS

A scoping review was conducted across six databases and grey literature to clarify intensivists' experiences of empathy and identify directions of future inquiries. The search had no date limits and was specific to empathy, intensivists, and ICU environments. Results were blindly and independently reviewed by authors.

RESULTS

The search yielded 628 manuscripts; 45 met inclusion criteria. Three overarching themes connected the manuscripts: (1) the risks and benefits of empathy, (2) the spectrum of connection and distance of intensivists from patients/families, and (3) the facilitators and barriers to empathy's development.

CONCLUSION

Empathy among intensivists is not a dichotomous phenomenon. It instead exists on continua. Four steps are recommended for optimizing empathy in the ICU: clearly defining empathy, addressing risks and benefits transparently, providing education regarding reflective practice, and developing supportive environments. Overall, this review revealed that the state of knowledge about empathy as experienced by intensivists still has room to grow and be further explored.

Medical Student Schwartz Rounds: A Powerful Medium for Medical Student Reflective Practice

PURPOSE

Reflection is a core component of good medical practice and of growing importance given increasing rates of burnout in the field of medicine. Schwartz Rounds (SRs) are a group-based model of reflective practice. This study explored the utility of student-specific Schwartz Rounds as a medium for reflective practice amongst medical students entering their first year of clinical attachments, and how effective these are compared to standard organisation-wide Schwartz Rounds.

METHODS

Three Medical Student Schwartz Rounds (MSSRs) were piloted over the course of a year at a major teaching hospital, focussed on the theme: "Is this what I signed up for?" Participants were asked to complete a questionnaire following the session, and this data was then analysed.

RESULTS

Feedback was obtained from 93% (42/45) students who attended. Ninety per cent of students rated the sessions as "excellent or exceptional", 93% felt the MSSRs added to their "insight and self-awareness", and 90% plan to attend SRs again in the future. A thematic analysis of the qualitative feedback highlighted three broad themes from the pilot; group reflection is more profound than individual reflection, sharing experiences facilitated a greater sense of belonging, and group reflective practice can be intimidating. There was a statistically significant difference between students' ratings of MSSRs, rated 8.67/10, versus written reflection, rated 4.64/10 (p<0.01).

CONCLUSION

Students were overwhelmingly positive about their experiences in this pilot, with response ratings commensurate with those from organisation-wide Schwartz Rounds. Therefore, MSSRs should be considered as a valid alternative form of reflective practice.

Assessing the benefits and usefulness of Schwartz Centre rounds in second-year medical students using clinical educator-facilitated group work session: not just "a facilitated moan"!

BACKGROUND

An experiential curriculum exposing medical students to the clinic early has many benefits but comes with the emotional stress this environment engenders. Schwartz rounds (SR) are an effective means to combat emotional stress and increasingly used in UK and USA hospitals. Recent studies show that the SR format may also provide benefits for medical students. This study aimed to investigate whether the guidance of SR in second year medical students provides the same benefits as to healthcare professionals.

METHODS

SR assessment involved 83 s year MBChB students in facilitated groupwork sessions. Topics discussed were "change and resilience" and "duty of candour". Students completed a Likert Scale questionnaire evaluating outcomes proffered by the Point of Care Foundation in collaboration with the Schwartz Foundation, with freeform feedback.

RESULTS

There was an 86% completion rate with 25% providing written feedback. Participants were more likely to agree than disagree that SR were beneficial. SR effectiveness in enhancing students' working relationship awareness and skills was strongly correlated with understanding the purpose of, and engagement with, the SR (P < 0.001). Similarly, engagement with the SR was strongly correlated with self-reporting of enhanced patient-centredness (P < 0.001). Freeform feedback could be grouped into five themes that revolved around understanding of the SR and engagement with the process. Many positive comments regarded the SR as a forum not only to "learn experientially" but to so in a "safe environment". Many negative comments stemmed from students not seeing any benefits of engagement with the SR, in that sharing experiences was "unbeneficial", "empathy is inherent and not learnt", or that sharing emotional problems is simply "moaning".

CONCLUSION

SRs are an effective way of fostering empathy and understanding towards patients and colleagues. However, for the students to benefit fully from the SR it is necessary for them to engage and understand the process. Therefore, for the successful implementation of SR into pre-clinical medical education, it is important to help students realise that SR are not merely a "facilitated whinge".

A qualitative exploration of the experiences of students attending interprofessional Schwartz Rounds in a University context

Schwartz Rounds are a cultural change initiative for interdisciplinary staff to reflect on their work to preserve the human connection. Their recent implementation in educational contexts means that there is limited research exploring the experience of students attending Rounds. This study aimed to develop understanding of how health-care students experience participation at Schwartz Rounds in a University context. Using an Interpretative Phenomenological Analysis approach, semi-structured interviews were conducted with eight health-care students about their experience of attending Rounds. Three themes were identified: ambivalence about safety to share "would it reflect badly on me?"; unifying through sharing emotions "you're not alone in feeling that"; and space to question professional cultures "there's not normally space given to that". The findings suggest that Rounds promote connectedness through humanizing professions and focusing on shared emotions; however, safety to share within Rounds can be limited by fear of judgment. This supports previous literature and suggests that Rounds may be well placed in educational contexts to support cultural change from the beginning of training.

Medical students' experiences with goals of care discussions and their impact on professional identity formation

CONTEXT

Goals of care (GoC) discussions occur amongst patients, family members and clinicians in order to establish plans of care and are invaluable aspects of end-of-life care. In previous research, medical learners have reported insufficient training and emotional distress about end-of-life decision making, but most studies have focused on postgraduate trainees and have been quantitative or have evaluated specific educational interventions. None have qualitatively explored medical students' experiences with GoC discussions, their perceptions of associated hidden curricula, and the impacts of these on professional identity formation (PIF), the individualised developmental processes by which laypersons evolve to think, act and feel like, and ultimately become, medical professionals.

METHODS

Using purposive sampling at one Canadian medical school, individual semi-structured interviews were conducted with 18 medical students to explore their experiences with GoC discussions during their core internal medicine clerkship. Interviews were audiorecorded, transcribed and anonymised. Concurrently with data collection, transcripts were analysed iteratively and inductively using interpretative phenomenological analysis, a qualitative research approach that allows the rich exploration of subjective experiences.

RESULTS

Participants reported minimal support and supervision in conducting GoC discussions, which were experienced as ethically challenging, emotionally powerful encounters exemplifying tensions between formal and hidden curricula. Role modelling and institutional culture were key mechanisms through which hidden curricula were transmitted, subverting formal curricula in doing so and contributing to participants' emotional distress. Participants' coping responses were generally negative and included symptoms of burnout, the pursuit of standardisation, rationalisation, compartmentalisation and the adaptation of previously held, more idealised professional identities.

CONCLUSIONS

GoC discussions in this study were often led by inexperienced medical students and impacted negatively on their PIF. Through complex emotional processes, they struggled to reconcile earlier concepts of physician identities with newly developing ones and often reluctantly adopted suboptimal professional behaviours and attitudes. Improved education about GoC discussions is necessary for patient care and may represent concrete and specific opportunities to influence students' PIF positively.

Compassion in palliative care: a review

PURPOSE OF REVIEW

Compassion has been recognized as a key aspect of high-quality healthcare, particularly in palliative care. This article provides a general review of the current understanding of compassion in palliative care and summarizes emergent compassionate initiatives in palliative care at three interdependent levels: compassion for patients, compassion in healthcare professionals, and compassionate communities at the end of life.

RECENT FINDINGS

Compassion is a constructive response to suffering that enhances treatment outcomes, fosters the dignity of the recipient, and provides self-care for the giver. Patients and healthcare professionals value compassion and perceive a general lack of compassion in healthcare systems. Compassion for patients and for professionals' self-care can be trained and implemented top-down (institutional policies) and bottom-up (compassion training). 'Compassionate communities' is an important emerging movement that complements regular healthcare and social services with a community-level approach to offer compassionate care for people at the end of life.

SUMMARY

Compassion can be enhanced through diverse methodologies at the organizational, professional, and community levels. This enhancement of compassion has the potential to improve quality of palliative care treatments, enhance healthcare providers' satisfaction, and reduce healthcare costs.

Clinical Debrief: learning and well-being together

Background

Clinical environments can be so stressful to medical students as to be detrimental to their learning and well‐being. Our intervention, Clinical Debrief, integrates learning through clinical experience with the development of positive coping strategies. Students shared cases and experiences during weekly small group classroom discussions, facilitated by general practitioners (from outside their current hospital placement), throughout two consecutive 12‐week blocks of their first clinical year. Alongside enquiry‐based and clinical reasoning learning, we gave students a safe space to reflect on their affect. Our aim was to critically examine students’ views in Clinical Debrief.

Method

Anonymised quantitative and qualitative evaluation data were collected over 3 years using online questionnaires on completion of each 12‐week block. The data relating to psychological supervision were analysed independently and in parallel, using thematic analysis for qualitative data.

Results

A total of 1857 evaluations were extracted (response rate 67%). The median (interquartile range) overall rating for Clinical Debrief sessions was 9 (8–10), where 10 indicates ‘excellent’ and 1 indicates ‘significant improvement needed’. The rating for the supervisory aspects of the sessions and free‐text comments were positive. Students appreciated safe environments, the session structure, facilitator role modelling, transitional support and processing of emotional experiences.

Discussion

Mandatory integrated longitudinal supervision, using trained clinician facilitators, was positively received by students in transition to clinical placements. Normalising the emotional impact of medical work destigmatises distress. Linking clinical reasoning with affective state awareness to contextualise case management, following Mezirow's transformative learning theory, brings added benefit to learning and well‐being. Student demand for the expansion of Clinical Debrief is evidence of success.

A realist informed mixed-methods evaluation of Schwartz Center Rounds® in England

Background

Schwartz Center Rounds®(Rounds) were introduced into the UK in 2009 to support health-care staff to deliver compassionate care, something the Francis report (Francis R.Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office; 2013) identified as lacking. Rounds are organisation-wide forums that prompt reflection and discussion of the emotional, social and ethical challenges of health-care work, with the aim of improving staff well-being and patient care.

Objectives

How, in which contexts and for whom Rounds participation affects staff well-being at work, increases social support for staff and improves patient care.

Design

(1) A scoping review of Rounds literature and comparison with alternative interventions; (2) mapping Rounds providers via a survey, telephone interviews and secondary data; (3) a two-wave survey of (i) new attenders/non-attenders in 10 sites to determine the impact on staff engagement and well-being; and (ii) interviews with Rounds attenders, non-attenders, facilitators, clinical leads, steering group members, board members and observations in nine case study sites to (4) describe experiences and (5) test candidate programme theories by which Rounds ‘work’ (realist evaluation).

Setting

(1) International literature (English); (2) all Rounds providers (acute/community NHS trusts and hospices) at 1 September 2014 (survey/interview) and 15 July 2015 (secondary data); (3) 10 survey sites; and (4 and 5) nine organisational case study sites (six of which also took part in the survey).

Participants

(1) Ten papers were reviewed for Rounds and 146 were reviewed for alternative interventions. (2) Surveys were received from 41 out of 76 (54%) providers and interviews were conducted with 45 out of 76 (59%) providers. (3) Surveys were received from 1140 out of 3815 (30%) individuals at baseline and from 500 out of 1140 (44%) individuals at follow-up. (4 and 5) A total of 177 interviews were conducted, as were observations of 42 Rounds, 29 panel preparations and 28 steering group meetings.

Results

(1) The evidence base is limited; compared with 11 alternative interventions, Rounds offer a unique organisation-wide ‘all staff’ forum in which disclosure/contribution is not essential. (2) Implementation rapidly increased between 2013 and 2015; Rounds were implemented variably; challenges included ward staff attendance and the workload and resources required to sustain Rounds; and costs were widely variable. (3) There was no change in engagement, but poor psychological well-being (12-item General Health Questionnaire) reduced significantly (p < 0.05) in Rounds attenders (25% to 12%) compared with non-attenders (37% to 34%). (4 and 5) Rounds were described as interesting, engaging and supportive; four contextual layers explained the variation in Rounds implementation. We identified four stages of Rounds, ‘core’ and ‘adaptable’ components of Rounds fidelity, and nine context–mechanism–outcome configurations: (i) trust, emotional safety and containment and (ii) group interaction were prerequisites for creating (iii) a countercultural space in Rounds where staff could (iv) tell stories, (v) self-disclose their experiences to peers and (vi) role model vulnerability; (vii) provide important context for staff and patient behaviour; (viii) shining a spotlight on hidden staff and patient stories reduced isolation and enhanced support/teamwork; and (ix) staff learned through reflection resulting in ripple effects and outcomes. Reported outcomes included increased empathy and compassion for colleagues and patients, support for staff and reported changes in practice. The impact of Rounds is cumulative and we have identified the necessary conditions for Rounds to work.

Limitations

Rounds outcomes relied on self-report, fewer regular attenders were recruited than desired, and it was not possible to observe staff post Rounds.

Conclusion

Rounds offer unique support for staff and positively influence staff well-being, empathy and compassion for patients and colleagues.

Future work

The adaptation of Rounds to new contexts and to increase reach needs evaluation.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Can Schwartz Center Rounds support healthcare staff with emotional challenges at work, and how do they compare with other interventions aimed at providing similar support? A systematic review and scoping reviews

OBJECTIVES

(i) To synthesise the evidence-base for Schwartz Center Rounds (Rounds) to assess any impact on healthcare staff and identify key features; (ii) to scope evidence for interventions with similar aims, and compare effectiveness and key features to Rounds.

DESIGN

Systematic review of Rounds literature; scoping reviews of comparator interventions (action learning sets; after action reviews; Balint groups; caregiver support programme; clinical supervision; critical incident stress debriefing; mindfulness-based stress reduction; peer-supported storytelling; psychosocial intervention training; reflective practice groups; resilience training).

DATA SOURCES

PsychINFO, CINAHL, MEDLINE and EMBASE, internet search engines; consultation with experts.

ELIGIBILITY CRITERIA

Empirical evaluations (qualitative or quantitative); any healthcare staff in any healthcare setting; published in English.

RESULTS

The overall evidence base for Rounds is limited. We developed a composite definition to aid comparison with other interventions from 41 documents containing a definition of Rounds. Twelve (10 studies) were empirical evaluations. All were of low/moderate quality (weak study designs including lack of control groups). Findings showed the value of Rounds to attenders, with a self-reported positive impact on individuals, their relationships with colleagues and patients and wider cultural changes. The evidence for the comparative interventions was scant and also low/moderate quality. Some features of Rounds were shared by other interventions, but Rounds offer unique features including being open to all staff and having no expectation for verbal contribution by attenders.

CONCLUSIONS

Evidence of effectiveness for all interventions considered here remains limited. Methods that enable identification of core features related to effectiveness are needed to optimise benefit for individual staff members and organisations as a whole. A systems approach conceptualising workplace well-being arising from both individual and environmental/structural factors, and comprising interventions both for assessing and improving the well-being of healthcare staff, is required. Schwartz Rounds could be considered as one strategy to enhance staff well-being.

Schwartz rounds in undergraduate medical education facilitates active reflection and individual identification of learning need

This article was migrated. The article was marked as recommended. Strategies applying Schwartz Rounds to improve wellbeing of medical students has focused on the clinical years of study. This pilot study investigates whether Schwartz Rounds could be effective in developing students' reflective practice in Year 2 undergraduates. Engagement with the Schwartz Round was high with over 50% of the students identifying learning needs through reflection on the Round. Schwartz Rounds promoted recognition of the value of reflective practice and increased self-awareness of student needs.

Improving patient safety by enhancing raising concerns at medical school

BACKGROUND

Doctors and medical students have a professional responsibility to raise concerns. Failure to raise concerns may compromise patient safety. It is widely known that medical students frequently encounter unprofessional behaviours in the workplace, but little is known about the barriers to raising concerns amongst medical students. This paper explores these issues and discusses some innovations in the medical undergraduate curriculum, offering a good practice model for other medical and healthcare curricula. We set out to ascertain the attitudes and experiences of medical students in relation to raising concerns. This data was then used to innovate the raising concerns curriculum, and access to the raising concerns system, in order to fundamentally improve patient safety and experience, as well as the student experience.

METHODS

The authors conducted a mixed methods quantitative and qualitative research study. Research was based at a UK medical school and involved data collection using an anonymous, voluntary survey emailed to all medical students (n = 363) as well as voluntary attendance focus groups (n = 24) recruited by email. Both tools investigated student attitudes towards raising concerns and explored student ideas for solutions to improving the process. The focus group data was thematically analysed by three researchers.

RESULTS

The authors identified five key themes which described medical student attitudes towards raising concerns. This article discusses these themes and the resulting work to enhance medical education within the medical school curriculum.

CONCLUSIONS

More research is needed to further address the barriers that medical students find in raising concerns. However, despite being a single study in one UK medical school, the authors propose some changes which they hope may inspire other educators to build upon their raising concerns curricula to foster more transparent undergraduate cultures and ultimately improve patient experience and safety.

Creating Structured Opportunities for Social Engagement to Promote Well-Being and Avoid Burnout in Medical Students and Residents

Increasing attention is being paid to medical student and resident well-being, as well as to enhancing resilience and avoiding burnout in medical trainees. Medical schools and residency programs are implementing wellness initiatives that often include meditation and other mindfulness activities, self-reflection, journaling, and lectures or workshops on resilience tools such as metacognition and cognitive restructuring. These interventions have in common the creation of opportunities for trainees to become more aware of their experiences, to better recognize stressors, and to regulate their thoughts and feelings so that stressors are less likely to have harmful effects. They often enable trainees to temporarily distance themselves mentally and emotionally from a stressful environment. In this Invited Commentary, the author suggests that medical school leaders and residency program directors should also create structured opportunities for trainees to establish meaningful connections with each other to provide greater social support and thereby reduce the harmful effects of stress. Social connection and engagement, as well as group identification, have potential to promote well-being and reduce burnout during training.

Compassionate collaborative care: an integrative review of quality indicators in end-of-life care

Background

Compassion and collaborative practice are individually associated with high quality healthcare. When combined in a compassionate collaborative care (CCC) practice framework, they are reported to improve health, strengthen care provision, and control health costs. Little is known about how to integrate and measure CCC, yet it is fundamentally applied in palliative and end-of-life care settings. This study aimed to identify quality indicators of CCC by systematically reviewing and synthesizing the current state of the palliative and end-of-life care literature.

Methods

An integrative review of the palliative and end-of-life care literature was conducted using Whittemore and Knafl’s method. Donabedian’s healthcare quality framework was applied in the data analysis phase to organize and display the data. The analysis involved an iterative process that applied a constant comparative method.

Results

The final literature sample included 25 articles. Patient and family-centered care emerged as a primary structure for CCC, with overarching values including empathy, sharing, respect, and partnership. The analysis revealed communication, shared decision-making, and goal setting as overarching processes for achieving CCC at end-of-life. Patient and family satisfaction, enhanced teamwork, decreased staff burnout, and organizational satisfaction are exemplars of outcomes that suggest high quality CCC. Specific quality indicators at the individual, team and organizational levels are reported with supporting exemplar data.

Conclusions

CCC is inextricably linked to the inherent values, needs and expectations of patients, families and healthcare providers. Compassion and collaboration must be enacted and harmonized to fully operationalize and sustain patient and family-centered care in palliative and end-of-life practice settings. Towards that direction, the quality indicators that emerged from this integrative review provide a two-fold application in palliative and end-of-life care. First, to evaluate the existing structures, processes, and outcomes at the patient-family, provider, team, and organizational levels. Second, to guide the planning and implementation of team and organizational changes that improve the quality delivery of CCC.