The healthcare team determines a 13-year-old girl with medically complex needs is ready for discharge—but her mother demands that she stay. As part of the team, what should you do?
A 2-month-old girl is admitted to the pediatric intensive care unit with multiple injuries; the diagnosis is nonaccidental trauma. The mother’s boyfriend had been babysitting and brought the infant to the emergency department because she wouldn’t wake up. She is intubated and has no spontaneous movement. How should you and your team work with this family to provide patient- and family-centered care?
A unique multidisciplinary forum, Schwartz Center Rounds® (SCR) provide a safe, comfortable setting in which caregivers can discuss difficult emotional and social issues, such as those described above. Unlike traditional rounds, which focus on the patient, diagnosis, and plan of care, SCR focus on the human dimension of health care. They give caregivers the chance to share their experiences, thoughts, and feelings on thought-provoking topics based on actual patient cases.
The premise of SCR is that caregivers are better able to make personal connections with patients and colleagues when they have insight into their own feelings and responses. To sustain compassion and prevent burnout, clinicians need a chance to reflect, share their challenges and successes, and support each other in ways not otherwise possible in their fast-paced work environment.
The Schwartz Center for Compassionate Healthcare, housed at Massachusetts General Hospital in Boston, developed the SCR format in 1997. Currently, SCR are held in 245 sites, including 34 organizations with Magnet® designation in 35 states. These rounds are expanding to new sites each month.
Caregivers sharing their perspectives
A hallmark of SCR is dialogue with the participation of professionals from diverse disciplines. The case-based format stimulates discussion on a given topic with a skilled facilitator who encourages interaction and highlights salient points. A clinician leader and planning committee choose a case and a panel of two or three caregivers to briefly share personal perspectives on the social and emotional issues involved. The rest of the hour is devoted to a give-and-take discussion, with caregivers in the audience sharing their perspectives and experiences. The facilitator (typically a social worker or psychologist) helps direct the discussion. Patient identifiers are omitted to protect confidentiality; all participants are expected to maintain caregivers’ confidentiality.
Typically, caregivers are trained to problem-solve and develop action plans, but that’s not the purpose of SCR, which encourage open discussion of emotions. A skilled facilitator can divert discussion from problem solving by framing issues from a different perspective. For example, at a rounds about an angry parent, the facilitator reminded participants that anger comes from fear. Recognizing this helped caregivers realize the anger wasn’t directed at them personally.
“Rounds are a place to come together and share support and validation for one another. They meet a deep need and fulfill a hole in the clinical community.”
SCR at Children’s Hospital at Dartmouth
In 2002, Children’s Hospital at Dartmouth (CHaD), part of Dartmouth-Hitchcock Medical Center in New Hampshire, introduced SCR after observing them in Boston. Although CHaD already had case conferences and ethics rounds, SCR offered a forum for a facilitated discussion and participation of a broad spectrum of pediatric providers and staff from both inpatient and outpatient locations. Participants in monthly SCR at CHaD include physicians, nurses, social workers, psychologists, physical therapists, care managers, hospital administrators, and clergy. Average attendance is about 40.
CHaD’s multidisciplinary SCR planning committee includes a chaplain, a physician, two nurses, a social worker, a child life specialist, and a facilitator. The committee publicizes SCR, schedules presenters from rotating departments, monitors evaluations, and plans the budget.
Cases and topics are chosen because they are particularly poignant or difficult and raise issues relevant to a wide range of caregivers. Some topics are selected for their timeliness. For example, during the H1N1 flu outbreak, one topic was titled “When you want the H1N1 flu shot and can’t get it, and when you can get a H1N1 flu shot and don’t want it.”
While attendees find SCR an overwhelmingly positive experience, a few challenges have arisen. For one, getting staff nurses to attend can be difficult. Rounds are at noon, and covering nursing staff for 1 hour isn’t always easy. Choosing a case in which a bedside nurse was very involved is a way to encourage other nurses and nursing leaders to attend.
Maintaining patient and staff confidentiality can be difficult, too. CHaD staff have learned how to set firm ground rules on confidentiality. They are encouraged to continue to discuss the topic on their floors or units without identifying the case or attributing specific statements to specific caregivers who attended rounds.
Benefits of SCR
A few years ago, the Schwartz Center hired an independent evaluation and research firm to conduct a comprehensive evaluation of SCR using a mixed-method approach and quantitative and qualitative data. It showed SCR have a unique and profound impact on caregivers as well as host institutions. Caregivers who participated in multiple rounds sessions reported:
- increased insight into the social and emotional aspects of patient care, greater compassion toward patients, and increased readiness to respond to patients’ and families’ needs
- improved teamwork, interdisciplinary communication, and appreciation for the roles and contributions of colleagues from different disciplines
- decreased feelings of stress and isolation, and more openness to giving and receiving support. (See SCR evaluation results by clicking the PDF icon above.)
“Rounds are a place where people are willing to share their vulnerability, to question themselves. They are an opportunity for dialogue that does not happen anywhere else in the hospital.”
SCR counter hospitals’ hierarchical structure by humanizing caregivers and creating an equal playing field. Many evaluation respondents said SCR make a unique and profound contribution, helping to change the culture of their organization and setting a new standard of care.
Participants have reported that insights gained at SCR have led to implementation of specific changes in departmental or hospital-wide practices or policies that benefit both patients and providers. The study found that the more rounds caregivers attended, the more benefits they experienced.
Rounds and the Magnet® environment
Incorporating SCR into the culture of CHaD supports a Magnet environment by providing a forum that encourages reflection on patient care. SCR foster an open dialogue, increased interdisciplinary collaboration, mutual respect, better conflict management, and collegial relationships. They allow staff to gain new knowledge and understand both the independent and dependent role of nursing as part of the care team.
SCR promote the model of patient- and family-centered care—a goal at Dartmouth-Hitchcock. Principles of patient- and family-centered care include respect and dignity, information sharing, participation, and collaboration. Respecting patient and family choices and developing a meaningful relationship can be difficult when the family’s choices differ from what caregivers may consider “right.” This dilemma is often at the heart of discussions in SCR, which offer a way to recognize and work through such conflict.
Fowler M, ed. Guide to the Code of Ethics for Nurses: Interpretation and Application. Silver Spring, MD: American Nurses Association; 2008.
Lown BA, Manning CF. The Schwartz Center Rounds: an evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, and provider support. Acad Med. 2010 June;85(6):1073-81.
Wolf G, Triolo P, Ponte PR. Magnet Recognition Program: the next generation. J Nurs Adm. 2008 April;38(4);200-4.
Visit www.AmericanNurseToday.com for a complete list of references.
Bridget Mudge is a pediatric clinical nurse specialist at Children’s Hospital at Dartmouth (part of Dartmouth-Hitchcock Medical Center) in Lebanon, New Hampshire. Marjorie Stanzler is Senior Director of Programs at the Schwartz Center for Compassionate Healthcare in Boston, Massachusetts.