Positive outcomes
Overall, the results of the study suggest that the SR was a constructive experience for the students. Most reported that the Round would have a positive impact on their patient care and relationships with colleagues through empathising with and appreciating their colleagues’ perceptions. Approximately 73% of students agreed that the SR enabled a greater understanding of the importance of empathy with patients. This is a similar proportion to the 80% of Year 5 and Year 6 students who found Schwartz Center Rounds enhanced their patient-centredness (Gishen et. al., 2016). They also describe a growth in confidence when it comes to handling non-clinical aspects of care, sensitive issues and challenging scenarios through learning from others’ experiences in the SR. Student 14 stated that “hearing others’ experiences has prepared me for potentially difficult situations” and for student 12 it taught them “how to deal with adverse reactions and situations”. Listening to others promoted a greater awareness of how to improve teamwork and connectedness. These aspects of Schwartz Center Rounds have not been investigated before in medical students, although a preliminary study did find an enhanced awareness of nonclinical, social and emotional aspects of caring for patients in hospital staff (Goodrich, 2012).
Following the SR, most students agreed that they had a better understanding of how expressing thoughts and feelings could help them, and that giving and receiving support is beneficial to helping them to feel valued. One commented that the SR highlighted the “importance of speaking up” (student 1). Those that understood the pertinence of expressing one’s thoughts and emotions were significantly more likely to benefit from the SR in a variety of ways. Not only were they more likely to come away from the SR realising the importance of attentiveness to social and emotional aspects of patient care, but also were the ones who enhanced their working relationship awareness and skills and their patient-centredness. This is the first study in either students or healthcare professionals that demonstrates that engagement with the Schwartz Center Round is key to gaining the advantages. Most other papers report a high level of feedback, which may indicate a natural willingness to engage in Schwartz Center Rounds. However, it may be worth considering the question of how to improve engagement when scheduling Schwartz Center Rounds in medical education.
The Role of Clinical Educators
Although the impact of CEs was not directly measured, there is evidence to suggest their inclusion was beneficial to the SR. The CEs assisted in the delivery of the session: they were fully briefed before the exercise and arrived prepared with relevant anecdotal experiences that reflected the themes in question. The CEs, who have graduated relatively recently, were able to reflect on their own experiences that they felt were most relevant to the students, or the difficulties and mistakes that students are most likely to encounter in the future. CEs were also able to share how they dealt with their emotions and resolved the issue. The GMC (2018) indicates that students “gain coping strategies by talking to their peers and from clinicians who are brought in to talk about real-life experiences [and] who have made mistakes” (“Make the over-riding message […], para. 2). Two students supported this evidence by confirming that “Clinical educators had useful past experiences” (student 15) and “advice was given to guide us […] which was somewhat useful” (student 1). However, it is difficult to determine whether the remaining comments refer to CEs or their colleagues. For example, student 16 thought it was “useful to share others’ experiences” and student 2 felt as though “they were telling stories from their time in hospital but I did not see how that would affect how I act around colleagues” without specifying whom they are referring to. This is the first study to report that the identity of the facilitators in a Schwartz Center Round, clinical or educational, may be important to its successful outcome. Given the recommendation of the GMC and the student feedback in this study, it may be advisable to consider the role of Clinical Educator in the learning environment when planning Schwartz Center Rounds as part of a curriculum.
Critical Feedback
Some students implied the SR was less relevant to them because they “already [felt] compassion” (student 18) and are “already […] professional, understanding and tolerant” (student 10). It could be argued that these compassionate role models should utilise the SR to support their peers who may benefit from an open discussion. In doing so, they may well gain something from the SR themselves as was demonstrated by those students who did engage. It may be that these students are less self-aware of their empathy skills. Student 10, who already feels compassionate, also likened the SR to a “complaints session” with “people just try[ing] to come up with more extreme stories of how they were victimised” (student 10). This feedback contradicts the student’s self-description and may demonstrate a lack of insight or understanding of how to maintain high levels of empathy through an exercise such as this. These students may be in danger of entrapment within a self-propagating negative cycle of “lack of awareness” leading to “non-engagement” leading to “non-beneficial Round” – leading to “no enhancement of awareness” and so on. Further work may be needed to improve Schwartz Center Round engagement as it may be that the students who would benefit the most from Schwartz Center Round are the ones most in danger of receiving no benefit.
Using the SR as a platform to complain was also identified by student 8 who felt that “forced group reflection is just another opportunity for those who are unlikely to have self-insight, or self-aggrandisement from telling their side of the story”. This student has perhaps not fully understood the purpose of an SR. It should be noted that SRs are not primarily intended to be Communities of Practice that spread skills but rather a platform to alleviate the emotional stress that comes with being a healthcare professional, which is achieved through participants sharing their version of events. Consequently, students who are described as complaining are voicing their emotions and using the SR as intended. It is then up to participants to seek a resolution or make sense of the emotions because everyone is valued equally. Therefore, it could be concluded that the purpose of the SR could perhaps be better explained to students beforehand in their briefing. It should also be explored how attitudes to compassion and empathy may be addressed to promote a more understanding environment.
Barriers to Contribution
Variations in age and cultural backgrounds may be partially responsible for divided opinion between students, though this set-up is similar to what one would experience from an SR in practice. Group sizes were relatively large which may have discouraged some students from expressing their views on more sensitive topics. For example, one student learned “how to handle racism and inappropriate comments” (student 12). Each room was arranged according to the students’ group work rooms meaning participants were surrounded by their familiar peers. It is unclear whether this encouraged or deterred students from speaking up. Equally, some students will have been in the same room as CEs who also act as their tutor. It may be that hearing the experiences of the CEs in a supervisory role makes it easier for students to share their experiences. While it is generally accepted that a multidisciplinary Schwartz Center Round is preferable, there have been no studies as to the effect of cultural diversity. This is an area that could be explored in the future, particularly as culture change has been reported as an influencing factor in (Deppoliti et al., 2015). There is the possibility that factors building barriers may be more evident in phase 1 students than the more experienced phase 2 students. An earlier study in year 5 and 6 students reported 77% and 37% form completion in these years respectively, however this report did not state the percentage completion of the “freeform” comments on their own (Gishen et al, 2016). The present study and a previous preliminary study (Stocker et al, 2018) both reported a greater overall feedback completion in Year 2 students than the clinical students in the Gishen report. If anything, this indicates a diminishing engagement with progressive years of study. None of these studies were designed to specifically address this question and this may be an important consideration for future study. However, it does appear that Year of study is not as great an influencing factor on engagement as other underlying factors may be.
It should be considered how student engagement could be enhanced, especially students who deem the exercise less valuable. For those who did not find it useful or did not directly contribute, it may be that they learned something in the process, such as how to process negative feelings towards others, or that it is acceptable to discuss one’s faults.
Challenges of Implementation
For SRs to be successfully implemented, several aspects should be considered including: the financing of the panel including CEs; a suitable period within the medical curriculum; and an appropriate space or area in which the SR can be held.
The Intended Outcome of the Schwartz Center Round
One student commented: “the session was more informative of how the rounds work better than breaking down relationship barriers amongst colleagues”, suggesting that the student benefitted from the SR by realising its value, however, for this particular student, they did not feel it broke down barriers between colleagues (one of the aims of an SR). This therefore raises the question: when introducing early-year medical students to SRs, should the intention be to introduce the concept and realise the value of open and non-judgemental discussion, or to function as an SR per se, alleviating sources of stress for students? It could be argued that either outcome is favourable as both will be useful for their future careers as doctors.
Take-home Messages
From this study, the authors feel that it is feasible to incorporate SRs into early undergraduate medical education. From the results, it is evident that most students feel that SRs will improve their patient care, teamwork and communication. There is a role for CEs in acting as an imperfect role model and providing a pertinence to the exercise. The results show that early-year undergraduate medical student generally engage positively with SRs and demonstrate an ability to empathise with each other and share feelings regarding early clinical exposure without inhibition. However, some students find SRs less helpful and feel their peers use it as a platform to complain. The correlation analyses suggest that the students who engage with the SR and gain an understanding of its purpose are also the students who gain the most awareness of the emotional needs of themselves, their colleagues and patients. Further research on self-rated compassion in early-year students along with the barriers to engagement may be useful.