By Karen Pugliese
In 2010, our palliative team began Schwartz Center Rounds at Central DuPage Hospital. Guided by co-facilitators (myself and a social worker), each month a panel of caregivers from diverse disciplines briefly describe their patient experiences, not from the medical model perspective, but from an emotional, human, reflective, and “feeling” perspective. Within a confidential, safe environment, panel members and participants focus on their patient-caregiver relationships. The format comes from the Kenneth B. Schwartz Center, which was founded “to support and advance health care in which caregivers, patients and their families relate to one another in a way that provides hope to the patient, support to caregivers, and sustenance to the healing process.” Clinical staff from every area of the hospital and outpatient settings explore our own personal responses, perceptions and prejudices in order to promote compassion toward patients and their families’ needs, as well as toward one another.
As increasingly challenging and complex situations surfaced during these meetings, we began to look into the rich resources in nursing literature highlighting continually shifting patient conditions such as acuity, life-and-death issues, technology, complex staffing models, caregiver-to-patient ratios, and workforce shortages. These issues, as well as appropriate and ethical care delivery, present sometimes overwhelming concerns for chaplains and other disciplines, as well as for nurses. Much research and many learning programs had been created to raise awareness and coping skills for syndromes such as burnout and compassion fatigue. Clinicians traditionally have had a difficult time talking about these skills because there hasn’t been a common language for understanding, quantifying, assessing and developing those competencies.
As far back as 1984, moral distress was seen as a key factor negatively affecting healthcare providers. Moral distress occurs when professionals cannot carry out what they believe to be ethically appropriate actions because of internal or external constraints. In 1993, nursing literature identified the stress caused by providers feeling tremendous sense of responsibility, but little authority. In 1995, research indicated that nurses and other providers who felt caught between the needs of the patient and the demands of hospitals experienced a strong tension between power and powerlessness. The consequences are far-reaching. Demonstrated long-term effects include decrease in self-worth, estrangement in personal and professional relationships, behavior changes and distressful physical symptoms. The effects do not diminish; each new experience leaves a new coating of psychic residue on the layers of distress already embedded. Although studies have focused on quantifying moral distress, there has been almost no research on what type of interventions are effective in reducing it.
As chaplains, we are not immune to these effects in ourselves and in the staff with whom we work. At CDH, one of our associate chief nursing officers, along with me and my social worker colleague, wondered if staff exposed to supportive interventions would exhibit greater resilience in coping with moral distress. We created a 24-month action plan featuring a three-pronged intervention process. A key component was our monthly Schwartz Center rounds, with additional opportunities for individual and group consultation and counseling, as well as cognitive learning sessions and using the Ethics Committee. Our findings indicated an overall decrease in moral distress scores between pre-intervention and post-intervention groups, and a significant difference in decline between control and experimental groups. Moral distress scores were significantly higher for those who were considering leaving their position.
And so we more purposefully integrated Schwartz Center rounds into our intervention plan. We intentionally related moral distress to the cases presented each month. We used one of the sessions to present a Schwartz Center webinar on moral distress. Every other week I would post eye-catching fliers in report rooms and locker rooms, reminding staff of signs and symptoms of moral distress, as well as available resources for coping. We instituted a moral distress hotline on each of our phones.
Schwartz Center rounds promote empathy and compassion toward patients and families, and foster openness to giving and receiving support from colleagues — something healthcare providers, including chaplains, often find difficult. Those who participated reported enhanced personal connections and improved insights into their own experiences, as well as increased appreciation of others’ roles and contributions.
Some of the evaluative comments we received include:
“I have had flashbacks and panic attacks upon coming back to work before. I never fully understood what was happening. Now I have a supportive community of co-workers.”
“The conversation from the panel and participants helped to normalize my own reactions.”
“I learned how to recognize the physical symptoms that resulted from what I was experiencing, and give it a name.”
It has been said that we teach what we need to learn. For me and my chaplain colleagues, Schwartz Center rounds inspired and encouraged us not only to address stressful, ethical and challenging situations with one another, but also with our clinical colleagues. We are more intentional about noticing signs and symptoms within ourselves and our coworkers, and more likely to seek “in the moment” support. We work with a heightened awareness of the importance of respecting self and staff determination in self-care. Last year, our Spiritual Care Resources Department provided nine days of reflection for employees focusing on personal, professional and spiritual resilience. We have committed ourselves to learn more about integrating emotional intelligence theory and somatic regulation interventions along with resilience theory in our ministry. And we come aside for a day of reflection ourselves each year to explore our inner space, and share with one another something of that sacred region deep within and far beyond ourselves where we discover ever-new meaning in our ministry.
Karen Pugliese, BCC, is an advanced practice chaplain at Central DuPage Hospital in Winfield, Illinois.
