What are Schwartz Rounds?
Schwartz Rounds (Rounds) provide a structured forum where all staff, clinical and non-clinical, come together regularly to discuss the emotional and social aspects of working in healthcare. Started by the Schwartz Center for Compassionate Healthcare, the Point of Care Foundation holds the license in the UK and supports healthcare organisations to introduce and sustain Rounds here. Typically they are hour-long meetings, held monthly with food provided. The hour begins with three or four members of staff (the panellists) presenting a particular topic or patient’s case – but with the focus on how caring for that patient (and their family) impacted on them emotionally. The rest of the hour is a facilitated discussion exploring the challenges of caring with compassion. The purpose of Rounds is to understand the challenges and rewards that are intrinsic to providing care, not to solve problems or to focus on the clinical aspects of patient care. Rounds can help staff feel more supported in their jobs, allowing them the time and space to reflect on their roles. Evidence shows that staff who attend Rounds feel less stressed and isolated, with increased insight and appreciation for each other’s roles. They also help to reduce hierarchies between staff and to focus attention on relational aspects of care [1, 2].
The underlying premise for Rounds is that the compassion shown by staff can make all the difference to a patient’s experience of care, but that in order to provide compassionate care staff must, in turn, feel supported in their work.
Ten years ago, during summer 2005, to commemorate its 10th anniversary, the Schwartz Center for Compassionate Healthcare asked hospitals to hold Rounds to discuss the topic, “What Makes for a Compassionate Patient-Caregiver Relationship?” Each facilitator was asked to guide the group discussion and distill practical suggestions for building compassionate patient-caregiver relationships. The discussion format was left to the individual hospital, but suggestions were made for a panel of patients and/or family members, a panel of caregivers (staff), or a focused discussion of the topic. 54 hospitals, over half the hospitals running Rounds in the US at the time, took part .
Ten years later with over 130 organisations running Rounds in this country, we (The Point of Care Foundation) wanted to mark the anniversary by repeating the exercise in the UK. This was not a research project but rather a chance to record a ‘national conversation’ about compassion. We thought it would be a good opportunity to explore the nature of compassion and what it means in practice, through conversations amongst people who are thinking about this every month in their Schwartz Rounds.
Definitions of compassion
First, though, it is useful to look at how compassion has been described and defined by others. The Point of Care programme adopted The Institute of Medicine’s definition of patient-centred care, which includes compassion as one of its dimensions [4, 5].
Compassion has been defined as ‘a deep awareness of the suffering of another coupled with the wish to relieve it’ . There is an understanding that compassion goes beyond acts of basic care, and is likely to involve generosity – giving a little more than you have to, and that kindness, and real dialogue are integral . Others have described compassion as a commitment to try to do something to prevent distress, which requires courage and wisdom . There seems to be an understanding that being compassionate is not easy and requires ‘acts of work and courage’ .
Can compassion be taught? In his book ‘The Compassionate Mind’ Paul Gilbert says that compassion is not as simple as an emotion or a motivation but there are specific skills and abilities which go into compassion (motivation, sensitivity, sympathy, distress tolerance, empathy and non-judgement) which can be taught and learned .
Further, compassion is described as including a sensitivity not only to the distress of others but to the distress of self as well . Personal qualities are important, and the notion of self-compassion (as Neff has described ) is one of these, and can be cultivated.
Importantly Cole-King and Gilbert emphasise that compassion is not the same as pity, because one person is not weaker or inferior to another in a compassionate relationship .
Participants in a workshop run by the Point of Care programme agreed that there were a number of factors that stop compassion . Professional training emphasises the importance of developing an ability to detach oneself from the patient’s distress and personal circumstances. Healthcare staff work in an environment where untreatable and terminal illness, disfigurement, suffering, and the pain of loss for patients and families can result in staff distancing themselves as a means of self-protection, which makes it more difficult to feel and show compassion. Isabel Menzies-Lyth famously wrote about the organisational defences that are put up against the anxieties caused by working in such environments. She argues that close contact with suffering, with physical and mental deterioration, with pain and distress and with death, arouses anxiety in all of us, and that actual physical contact with strangers and with their bodies is taboo .
In order to protect themselves from such anxiety health professionals need to be sure that they don’t identify with patients.
Regular and constant exposure to human suffering causes stress and has a blunting effect, unless there are mechanisms in place to support staff and help them process their experiences.
Burnout produces stress, and at its extreme, produces a lowered sense of personal effectiveness, emotional exhaustion, and depersonalisation of others which can limit compassion, and at its most extreme cause cruelty towards patients . Others have explored whether some patients are easier to look after than others. Some patients are less attractive, more difficult, more frightening and challenging than others: there are always unpopular patients [15, 16].
There are a number of factors which enable compassion. Support from colleagues, good team working, and time for reflective practice, are all strategies which can mitigate the diminishing of compassion . Although there is still debate about whether compassion (and empathy) can be formally taught, or measured  there is agreement that role modelling by colleagues, is a powerful way of learning how to behave compassionately.