Sharing the burden: Schwartz rounds® as a compassionate collaborative practice and education model in long-term care

Background: Caregivers in long-term care often struggle to manage the holistic care for residents who have complex health needs, and are nearing end-of-life. Schwartz Rounds® promote compassionate inter-professional education and practice, thus have potential to improve team relationships, resident care, and retention of long-term care caregivers. These Rounds promote open and honest dialogue about feelings that emerge as a result of caregiving. Through sharing this burden, the Rounds can improve how inter-professional teams care for self and others. Objectives: In this paper, we report the results of a literature review that was used to develop a protocol for Schwartz Round implementation in long-term care settings. Methods: We conducted a literature review to understand the nature and implementation of Schwartz Rounds. Following a keyword search of various databases, we retrieved, reviewed and integrated evidence about protocols and processes for conducting Rounds. Experts in long-term care reviewed and contributed to the protocol development. Results: Rounds are structured monthly opportunities through which professional and non-professional caregivers can share feelings and responses to specific resident care issues. A team member frames the topic and encourages discussion. A panel of caregivers participate in roundtable dialogue regarding a real resident case. The discussion generates awareness of emotional care responses, and support for team members. Conclusions: Implementing Schwartz Rounds in long-term care has potential to improve compassionate collaborative practice and education, combat compassion fatigue, improve resident care, and retain the long-term care workforce. Leadership at the point-of-care and administrative levels are essential for overcoming implementation challenges. Correspondence to: Kathryn Pfaff, RN, PhD, Assistant Professor, Faculty of Nursing, University of Windsor, 401 Sunset, Windsor, Ontario N9B 3P4, Tel: 519-253-3000; 519-253-4977; E-mail: kpfaff@uwindsor.ca


Introduction
Long-term care residents have complex health concerns and geriatric syndromes. The vast majority of persons who reside in longterm care homes will die in these homes. Inter-professional education and care is a requisite for high quality health care [1], and in long-term care homes, both are needed to comprehensively address the multiple co-morbidities, and psychosocial and spiritual needs of these residents from admission through end-of-life. This is demanding and labour intensive work [2], and it can have negative consequences on care providers and organizations, such as, impaired health care provider health, poor team functioning, and staff turnover. Building and maintaining a sustainable long-term care workforce is a global priority [3], and collaborative education and practice must be prioritized in long-term care strategies.
Fully realizing collaborative education and practice has challenges in most health care settings, and long-term care is no exception. We assert that compassion breaks down the barriers, and when integrated in collaborated practice and education models, it can support positive resident and healthcare provider outcomes at end-of-life [4,5]. Compassionate collaborative practice involves engaging care providers to compassionately care for the self and others within the context of the Inter-professional practice [5]. It provides support to experience and act with compassion towards all who deliver and support healthcare, while also promoting personal and professional education, wellbeing, and resilience [4].
In this paper, we present an adapted protocol for Schwartz Rounds that can be implemented to enhance compassionate collaborative education and practice in long-term care homes. Considerations for planning and case identification are discussed. Practice and research implications are also summarized in the discussion.

Methods
A comprehensive literature review was conducted to understand the nature of Schwartz Rounds, its utilization, and outcomes in longterm care. Search engines included CINAHL Complete, Pubmed and ProQuest. Keywords were used in a variety of combinations and included "Schwartz", "rounds", "compassion", "empathy", "long-term care" or "long term care" and "collaboration". No restriction on date, the country of the publication, or location of practice of Schwartz Rounds was placed on the articles. Searches were narrowed by selecting articles that reported protocols and processes for conducting Schwartz Rounds, as well as those that reported outcomes, such as caregiver emotional status and satisfaction, and quality of patient care.

Results
Fifteen articles were retrieved, eight of which were narrative summaries of Schwartz Rounds that were conducted at The Kenneth B. Schwartz Center at Massachusetts General Hospital, Boston, Massachusetts, USA. The literature sample reported data from the United Kingdom and United States, with few reports from other counties. There were no studies evaluating Schwartz Rounds in longterm care. Based on the literature available, we present an adapted Schwartz Rounds protocol and process for implementation that can be used in long-term care.

Important considerations for planning
Schwartz Rounds are structured around a protocol, and include many components that must be coordinated to be effective [8,13]. We recommend that Schwartz Rounds champions be recruited to plan and coordinate the rounds; nevertheless, the engagement of all carers in the process is essential. Organizational factors, such as time and space, must be considered before implementation [8,13].
The literature suggests that Schwartz Rounds be conducted monthly [13]. It is recommended that food and refreshments be available in the same setting in which the rounds are implemented [7,8,13]. In longterm care, time away from resident care must be prioritized. Scheduling around the staff lunch time may take advantage of time when staff are away from the unit [8,13]. An alternative strategy in long-term care is to schedule Schwartz Rounds during times when resident care needs are met, for example, during resident rest periods and/or after comfort care rounds are complete. Regardless, staff coverage for participants is essential to avoid interruptions. A practical suggestion is to rotate the monthly rounds across neighbourhoods or units within a long-term care home. Staff from non-participating neighbourhoods will cover the resident care needs of the unit whose care team is participating in rounds.

Identifying an issue or case
Cases can be suggested by any member of the care team who has experienced, or is currently experiencing, an emotional response to some aspect of caring [7,8,14]. Cases are selected by a panel of carers who also serve as champions and frame each case. Examples of common issues that have an emotional impact on carers in long-term care homes include: depression and suicide [18], resourcing, quality of life, end-of-life decision-making, family relationships, advance care planning [19], and spirituality [20]. Furthermore, issues related to sexual expression [21], marijuana use [22], and physician assisted dying [23] are emerging, and will require compassionate and honest team dialogue.

The protocol
Schwartz Rounds are opened by a facilitator [7]. The facilitator does not necessarily require a background in nursing or medicine, but should have the right skills set to be able to encourage dialogue and help participants feel at ease [8,17]. The goal of facilitation is to keep the discussion focused on the emotional aspects of caring, rather than problem solving or debating care decisions [8,17]. We suggest a registered nurse, nurse practitioner, social worker, physician, or pastoral care provider as having the educational preparation and interpersonal experiences to accomplish this goal, but other team members with these unique qualities may also be considered. Consideration may be given to selecting a facilitator from outside the care home [7].
After welcoming participants, the facilitator introduces the topic and purpose of discussion while emphasizing its confidential nature, adding that resident names have been changed and that the topics discussed should not be shared outside the environment [8,17]. Cell phones and pagers should be silenced [7]. Next, the resident panel case presents the topic of case. The resident care panel is made up of professional and non-professional members: personal support workers, dietary staff, recreational staff, volunteers and students. Krakauer, et al. [2] highlight bereavement benefits for family participation in the rounds; however, the ethics associated with confidentiality would need to be considered in the long-term care context.
The resident panel provides a short summary of the resident's story, how each carer played a part in the care of the resident, the environment, and the emotional challenges that they may have faced [7,8]. The floor is then open to a round table discussion [7,8,17] where other individuals present in the room are given the opportunity to share similar experiences, thoughts and reflections on how to face these challenges in care, and/or pose new or alternative perspectives [8].

Protocol box
Overview of How Schwartz Rounds May Be Organized in Long-Term Care  Gather care team -professional and non-professional carers

Discussion
The integration of Schwartz Rounds in long-term care has great potential for promoting compassionate collaborative education and practice in long-term care, and its care provider and organizational outcomes [8,[13][14][15][16]. It is important for professional and nonprofessional care providers to have opportunities to learn from one another. Physical space, and time to collaborate are levers for enhancing collaborative practice and education at the practice level [1], and both are embedded in this proposed model. Further, the Rounds provide an "even playing field" [7] through which meaningful and open conversations can occur. Reducing professional hierarchies through Schwartz Rounds could be immeasurably valuable, especially for non-professional carers, such as personal support workers whose turnover rates are higher than professional staff. That is, the time to reflect and learn together can support how compassion is integrated in teams, care processes, and organizational culture [8,17,24]. The perspectives of non-professional staff are just as important as physicians and nurses [7]. The rounds can support team development and coping mechanisms that protect against burnout and improve organizational culture [16,24]. That is, "rounds are consciously linked to work on culture change... how we look after our staff, who then give better care; there is good evidence for this" [8].
Nevertheless, implementation requires strong and committed leadership at the point of care and administrative levels. Champions can engage and educate coworkers about compassion fatigue, and how this intervention can combat this very real phenomenon [17]. Administrative leaders must contribute sufficient resources: human resources for facilitation and evaluation, administrative support, refreshments, publicity, time, and space. Organizations are encouraged to consult with the Schwartz Center for Compassionate Care prior to implementing.
We are currently engaging long-term care homes to develop a pilot implementation project. In the short-term, we will evaluate its process and impact on coping and caregiver stress. This will involve a mixed methods approach so that both qualitative process data can be triangulated with quantitative data to inform the intervention protocol. A larger project will quantitatively evaluate outcomes such as retention, turnover, burnout, compassion fatigue, and engagement in collaborative practice.

Limitations
This review reflects a small body of literature that is of relatively weak quality. Among the articles retrieved, most discussed the implementation of Schwartz Rounds in acute care and cancer facilities. None were specific to long-term care; however, long-term care experts were invited to review and contribute to the protocol. Despite these limitations, the benefits are highly promising.

Conclusion
Schwartz Rounds are an innovative model through which compassionate collaborative practice can be operationalized [4]. These rounds provide the space and time for care providers to share the emotional burden of caring, by discussing insights, feelings and responses that stem from the challenges of caring [6]. Long-term care delivery is complex and emotionally and physically demanding. It requires that care providers share knowledge and compassion within the team [4,5]. It also requires organizational leaders who foster a culture of compassion and prioritize self-care. Being connected with others "fuels personal growth and is a powerful force for healing… an opportunity for changes in values, goals, or direction; healthier behaviors; an improved sense of self; and increased productivity, energy, and creativity" [10].