Mini Review - (2022) Volume 16, Issue 2
Received: 24-Dec-2021, Manuscript No. Iphsj-21-12170; Editor assigned: 26-Dec-2021, Pre QC No. Preqc No.12170; Reviewed: 07-Feb-2022, QC No. iphsj-21-12170; Revised: 12-Feb-2022, Manuscript No. phsj-21-12170(R); Published: 21-Feb-2022, DOI: 10.36648/1791-809X.16.2.912
Objective: Schwartz rounds provide opportunities for staff in healthcare to reflect on their experiences in a confidential setting. Newcastle upon Tyne have been running Schwartz rounds for several years. In early 2020, all in person meetings were cancelled, including Schwartz rounds. The decision was made to continue Schwartz rounds virtually to continue to provide a space for reflection. The study explored the experiences of staff and facilitators in transitioning from in-person, to virtual Schwartz rounds.
Methods: Those in attendance were offered an opportunity to provide feedback through an email link to a survey. This included quantitative and qualitative feedback, such as describing how they found the round, particular challenges and parts which were helpful and a comparison between them and in-person Schwartz.
Results: Feedback was obtained by 398 individuals between March 2020 and July 2021. Facilitator’s feedback was obtained from those involved in running the rounds, including how they found the move to virtual Schwartz and any challenges and benefits of virtual Schwartz. Virtual Schwartz was associated with increased attendance, increased accessibility and was seen as impactful as face-to-face Schwartz. Analysis of the listener’s feedback identified seven themes. The themes were ‘Building Relationships with Colleagues”, “Guilt”, “Appreciation of rounds around COVID-19”, “Technology”, “Bringing together” and “Accessibility”. The themes from the facilitator’s feedback were “Pride in persevering”, “Technology”, “More effortful Connection”, “Accessibility” and “Anonymity”.
Conclusion: Overall, virtual Schwartz was seen as a positive and supportive environment which provided a new opportunity for people to feel connected to those who had experienced similar situations throughout the pandemic. There were challenges for the facilitators with the move to virtual Schwartz, including technology and difficulties being there for speakers and listeners. However, virtual Schwartz was seen as worth pursuing to provide a safe space for reflection throughout the COVID-19 pandemic.
COVID-19; Schwartz rounds; Virtual; Staff support; Reflection; Facilitators; Healthcare staff; Pandemic
Schwartz rounds have been running monthly within the Newcastle Upon Tyne Hospital Trust (NUTH) since 2015. These aim to provide a confidential space whereby all staff can come together to discuss the emotional and social impact of working in healthcare [1].
The rounds are guided by trained facilitators. A panel of two or three staff members share their experiences around a theme. The emphasis is on the emotional impact of the experience, as opposed to describing events that have happened with the audience encouraged to share their thoughts and reflections on the stories they have heard. The focus of the round is to ensure the focus is not problem-solving, but reflection; this is maintained by the facilitators who guide the speakers and audience through shared reflection and shared experiences.
Schwartz rounds were developed as an in-person group meeting, with the focus on the shared experiences of the attendees. In 2020, at the start of the COVID-19 pandemic, NUTH (along with other UK healthcare Trusts) cancelled all face to face meetings, including Schwartz Rounds. However, this was at a time when all NHS staff were faced with significant and unprecedented challenges, including a more extreme and demanding working environment. This brought emotional challenges including maintaining the safety of patients and staff, the uncertainty surrounding the healthcare impacts of COVID-19, as well as additional stressors related to the personal and professional lives of staff members. There was also a rapid shift in physical working locations, including redeployment to often previously unknown working areas or working from home. The media emphasis on the NHS was sustained and intense.
Alongside the logistical demands of COVID-19, NUTH as an organisation quickly realised the need to prioritise staff wellbeing. A key component of this was to maintain Schwartz Rounds but in a virtual format ('virtual Schwartz'). This report highlights the planning, evaluation and learning gained from this transformation.
Planning
As an established Schwartz Round organisation, NuTH had several trained facilitators with the capacity to support digital transformation. The consensus was to maintain the key principles of Schwartz, including the focus on the speakers' stories, facilitated group discussion, and shared emotional learning. It was also agreed that the focus, particularly initially, needed to be around the pandemic and impact.
To meet the principles of Schwartz, the digital platform had to be able to meet certain demands. These included open access for everyone in the organisation; both audio and video; the ability to be controlled by the facilitators; audience participation. Two platforms were used in line with changing policies within the organisation (Star leaf and Microsoft Teams) and both were able to meet the facilitators' requirements.
There were initially questions around whether the technology would be sufficient to support the virtual format, and whether virtual Schwartz would have the same emotional impact as in person events. In order to answer this question, evaluation was deemed to be important and adaptation of the in-person feedback was required. Additional questions related to how virtual Schwartz helped in times of COVID-19 and how virtual Schwartz compared with face to face Schwartz and a link to this was emailed to each individual.
Finally, the facilitators recognised that this transformation required additional support and training for themselves. It was agreed to separate the IT requirements from the facilitation to maintain the focus on the emotional stories and audience participation. The key messages for the Round, which usually included the background to Schwartz and 'rules' such as confidentiality were broadened to include digital rules such as keeping on mute and disabling the chat function and also highlighting key areas of support for staff with emotional difficulties. To evaluate this change, facilitators were sent a brief questionnaire by email. This asked questions related to how facilitators found the move to virtual Schwartz, IT support, challenges and benefits and how they found managing emotional responses virtually.
Results
Demographics
In the time period, March 2020 - July 2021 fourteen virtual Schwartz Rounds were held and 398 individuals provided feedback. Individuals had various job roles including nurses, midwives, medical doctors, administrative and clerical staff. For the facilitator's feedback, all five facilitators provided feedback.
Across this period, ¼ of the participants attended their first round. The average attendance for the six in-person rounds before March 2020 was 72 individuals per round. The average attendance for six randomly picked virtual rounds was 94 individuals per round. 44.31% of participants had not attended a face to face round. Almost half of the individuals (49%) who provided feedback either stated that they preferred virtual Schwartz or liked both face to face and virtual Schwartz equally. Participants rated the accessibility of virtual Schwartz as very easy or easy (81%).
At the beginning of virtual Schwartz, some technical difficulties likely impacted people's experience of the rounds. As the rounds continued, there were less negative comments related to technical issues on the evaluation feedback discussion around technical issues. For example, negative feedback in the initial virtual rounds included difficulties with sound quality, availability of necessary technology, not being able to privately use technology and the technology not working. In later rounds, the free text comments on evaluation focussed on listening to difficult stories and the emotive response and navigating emotions on a virtual platform.
Attendees that had previous experience of face-to-face Schwartz were asked to compare their experiences. The majority found virtual Schwartz as impactful (71.3%) and the discussion as useful (59.8%) as face to face experiences.
Previous Schwartz research, including from our institution, has used qualitative feedback to highlight emergent themes that support the emotional impact of Schwartz Rounds [2, 3]. We have looked at the qualitative feedback and highlighted some dominant themes using the thematic analysis from our previous research. Six themes related to participants' experiences of Schwartz Rounds throughout the covid-19 pandemic were generated. These include 'Building relationships with colleagues’, 'Guilt', 'Appreciation of rounds around COVID-19, 'Technology', 'Bringing together' and 'Accessibility'.
Building relationships with colleagues
Participants recognised that virtual Schwartz helped them realise they were not alone in their experiences. "The discussion showed me I was not alone and enabled me to embrace my anxieties about COVID-19".
There was a discussion around it being an "excellent opportunity to hear how colleagues are feeling at this unusual time", and that it helped emphasise the feelings of being "part of a team" despite the inability to see each other in face to face settings.
Guilt
One theme which often came out in the Schwartz discussions was around guilt during the COVID-19 pandemic, "hearing similar thoughts such as guilt at not being as busy as other departments, not enjoying the clapping for NHS workers", and that "it was brave of one of the speakers to talk openly about how she did not feel deserving of the NHS hero's labelling".
Participants appreciated the shared experience of guilt, with one individual stating "I felt reassured it was okay to feel these emotions as they validate our humanity, and hasn't this always been the purpose of the Schwartz round". Although Schwartz was not originally designed for the pandemic, this shows its ability to adapt to changing experiences, such as the increased focus on NHS staff and staff's reaction to this. Participants felt able to relate to these shared experiences of guilt.
Appreciation of rounds around COVID-19
Individuals reflected that it has been helpful for people to share their experiences of COVID-19 with colleagues, and reflect on how it has been for them personally, as well as professionally. "This round gave me a chance to really think about how Covid has affected me, my work and my family. It has been a very difficult juggling act and I haven't always got it right. It has made me think what I can do more to support other colleagues and how to get through what is to come myself".
There was usefulness in having different sources of people's COVID-19 experiences within the NHS, and that this opened up further conversations within teams. This impact was demonstrated by one participant stating "This was a brilliant session to listen to; it really helped me reflect on my own experiences. Our team ended up having a discussion afterwards, which enabled us to speak about difficult situations we have been through and support each other on this".
Technology
Virtual Schwartz relied on participants navigating the platform used and understanding the rules that came with this. One particular challenge was the lack of a confidential space: "I did not have a confidential space to interact so was not able to make a response", "Unless in a private room, cannot fully participate". This was an unanticipated challenge of virtual Schwartz.
However, if participants can find a private space to take part, there may be an added anonymity to the virtual element. "The option to remain anonymous is always helpful actually, because some people just want to listen to the stories and reflect at a later time". This may allow an opportunity for people to control the level of disclosing, for example turning their camera on if they want to share, or muting themselves if they need to take some time away.
Participants did comment on technological difficulties including sound quality, the need for muting and cameras off for attendees. People also had a preference for people sitting in the same room with a "camera panning between speakers" as this was "more professional and less distracting for viewers than swapping chairs".
Bringing together
Experiences were shared from individuals from all types of careers, and there was an overwhelming sense of unity and a greater sense of working together and less separation between different roles. One participant described a round as "unifying – in terms of being part of the same organisation… we rarely hear about the experiences of colleagues who are not within our circle of people with whom we are in routine contact".
The most recent virtual Schwartz brought about an opportunity for individuals to reflect retrospectively on what COVID-19 had meant for them and their work and that this unifying effect will last beyond COVID-19. "It also reminded me of how we got through with the support of colleagues - often people we hadn't ever worked with before. The statement that we are no longer the Freeman and the RVI but Newcastle Hospitals rang true and that we are proud of what we do".
Accessibility
Virtual Schwartz has allowed Schwartz to be much more accessible, and therefore more people could reap the benefits of Schwartz. This includes those working at different sites, or those who are unable to leave their place of work. Schwartz would be "beneficial for those staff that aren't able or won't travel to Royal Victoria Infirmary / Freeman Hospital to get involved".
Virtual Schwartz allowed those who may be put off by having a room full of people attend, with one participant stating that "I found it much better via Star leaf as it made me feel much more at ease, sometimes a full lecture theatre can feel overwhelming and anxiety provoking". It also may provide "a great chance to come together when we are often feeling isolated".
Facilitator's feedback
Facilitators were also asked to provide feedback on their experiences of virtual Schwartz. Themes were collated from this feedback. The themes were 'Pride in persevering', 'Technology', 'More effortful connection', 'Accessibility' and 'Anonymity'.
Pride in persevering
There were discussions that this is a new way of working, with one facilitator stating they were "initially quite anxious" and that they "couldn't see how it work virtually and what it would mean for discussion".
There was also a sense of pride at persevering, with one facilitator stating "I felt proud that we prevailed despite the technological challenges". The importance of teamwork in doing this was mentioned, "I found the move from face to face to virtual a challenge, but made easier with the support of the whole Schwartz team". Overall, virtual rounds allowed a responsive and supportive network to continue for staff.
Technology
Technology was mentioned by all facilitators. There was an acknowledgement of the difficulties, such as it being "unfamiliar and unreliable", and that the move to virtual rounds "was difficult at first, particularly the first rounds where we were still unfamiliar with the technology". This seemed to become easier, and "the majority of people seemed to accept that this is the new normal".
In terms of technical support, the importance of having technical support was discussed. It was universally agreed that it would not be possible to run rounds without additional technical support in addition to two facilitators. The delivery of rounds was significantly improved when facilitators were given rooms with headsets, laptops and a stable internet connection.
More effortful connection
The facilitators discussed maintaining a connection with speakers and audience members was more effortful to manage, such as "It is much harder to support emotional responses virtually, but not impossible". This may be due to the lack of non-verbal cues. Each facilitator mentioned the difficulties of not seeing "reactions and unspoken emotions". This was discussed in terms of audience members, managing what people think of the speaker's story and the speakers. One facilitator stated that they "worry that it is strange for speakers to speak to a camera and not to have nodding, listening faces in front of them".
Although it can be more effortful to have the same connection as face to face, ways around this were mentioned. For example, "responding to people who switch on their camera and speak, as it feels you can connect to them to a degree"
Accessibility
There was recognition that providing virtual rounds made them more accessible for most people. A strength of virtual rounds was that "lots of people who would otherwise not find the rounds accessible have joined" and has allowed "a more rounded representation of the trust staff at each round". Virtual rounds may be more inclusive for those with disabilities or deficits in things like hearing, or sight. One facilitator stated "when people do speak you can often hear them well", whereas in "large audiences it was hard for the audience to hear or see people who contribute from the audience".
Anonymity
It is clear that in virtual rounds, there is greater anonymity amongst the audience. This can work in two ways. For some people, they prefer talking to an "anonymous and faceless audience". On the other hand, there was feedback that some people feel more reluctant to speak as they do not know who is in the audience.
We have presented our experience of a rapid move from in person to virtual Schwartz in a large healthcare Trust in the North of England. Feedback from participants has been positive and supportive.
The increase in new participants attending virtual Schwartz is a positive finding and suggests that the virtual format is more accessible to staff who may not be able to leave their workplace. Virtual Schwartz was a new opportunity for people to feel connected to those who have been in similar situations throughout the pandemic. Participants that had attended in-person Schwartz found the virtual format as emotionally impactful. This was an unanticipated outcome as we had been concerned that the emotional side of Schwartz would not come across on the virtual platform.
We chose to focus on the pandemic in the Rounds during this time. The themes arising from the qualitative feedback were overwhelmingly supportive of this focus and highlight the importance of providing emotional support during the pandemic. Indeed, in response to feedback, the Schwartz facilitators highlighted other areas of emotional support available in the Trust.
The rapid shift to virtual meetings has been a steep learning curve for many in healthcare. We accept that both anticipated and unanticipated challenges arose during the virtual Schwartz Rounds. Simple housekeeping rules such as reminding participants to mute and turn off cameras were integrated into the Schwartz introduction but also became easier over time as we became more accustomed to this form of communication. For some participants, the anonymity that came with attending virtually seemed to be a positive and perhaps was less emotionally stressful than in-person attendance.
The facilitators highlighted similar themes to the audience members. The transition from face to face, to virtual, had its challenges, such as managing an emotional response virtually and technology. However, there was a sense of pride in transitioning to virtual and an acknowledgement that this had positives, such as increased anonymity and accessibility meaning Schwartz could be accessed by a wider range of individuals.
We have shown that Schwartz Rounds can be successfully run in the virtual format, with similar emotional impact and high attendance rates. Ideally, technology needs to be embedded and freely accessible within the organisation. Schwartz Rounds focusing on the impact of the pandemic have been welcomed and have provided an important source of emotional support during this difficult time.
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Citation: Farrell FJS, McKendrick F, Jandial S (2022) Exploring the experiences of healthcare staff and facilitators transitioning from in-person to virtual Schwartz Rounds throughout the COVID-19 pandemic. Health Sci J. Vol. 16 No. 2: 912.
