Clinical Educator-Facilitated Schwartz Centre Rounds in Second-Year Medical Students: “A Facilitated Whinge”? CURRENT STATUS: REVIEW

Background Medical students are increasingly being exposed to the clinic at early stages in their education, with the benefits becoming widely realised. This early exposure to such a highly pressurized environment can result in increased levels of stress and emotional unrest. Schwartz Center Rounds, reflective forums primed to aid social and emotional issues healthcare professionals’ experience, are now a relatively common and effective means to combat these effects in hospitals in the UK and USA. Recent studies show that the Schwartz Center Round format may also provide positive benefits for medical students. It has been suggested that students may be able to develop good coping strategies from discussions with “real” professionals. Methods This study investigated whether the guidance of Schwartz Center Rounds in year 2 of an MBChB by junior doctors enriches students’ appreciation and benefits of the Schwartz Center Round. Results The results reinforce the concept that Schwartz Center Rounds are an effective way of fostering empathy and understanding towards both patients and colleagues. Moreover, the facilitation of the Round by Clinical Educators, who also act as an imperfect role model, provides a pertinence to the exercise. The results show that early-year undergraduate medical students generally engage positively with SRs and demonstrate an ability to empathise with each other and share feelings regarding early clinical exposure without inhibition. However, correlation analyses suggest that engagement with the Schwartz Center Round is fundamental to gaining an understanding of its purpose and concurrently gain the most awareness of the emotional needs of themselves, their colleagues and patients. Conclusion Schwartz Center Rounds are an effective way of fostering empathy and understanding towards patients and colleagues in the healthcare environment. There is some evidence that the inclusion of Clinical Educators made the Round feel more pertinent to the students with the junior doctors’ clinical experiences being described as a useful addition to the discussion. Moreover, the students that benefitted most from the Round were the ones who engaged with and understood the process best and therefore it is important to help students realise that Schwartz Rounds are not merely a “facilitated whinge”.

respectful towards colleagues and patients (Adamson et al., 2018;Goodrich, 2012;Robert et al., 2017). Though initially designed for hospital staff, SRs have been piloted with Year 5 and 6 medical students, with the majority agreeing that it was a useful tool giving insight into others' views (Gishen et al., 2016). Results have been similarly encouraging when looking at incorporating SRs into earlier stages of training, specifically second-year undergraduates with limited clinical exposure. However, this resulted in some respondents feeling as though their inexperience reduced the effectiveness of the exercise (Stocker et al., 2018).
If effective, SRs may have the potential to be used as an educational tool to enhance reflective skills to better prepare students for their future careers as doctors. Questions remain as to whether SRs could effectively be incorporated into undergraduate medical curricula and if so, how they might be adapted to enhance the experience for early-year students who have limited clinical exposure. This study allowed learners to discuss both non-clinical and clinical scenarios in an SR facilitated by 'Clinical Educators' (CEs), that is junior doctors with an interest in medical education, most of whom have just completed their Foundation Year 2 training. They provide 'near-peer' support to students and facilitate interactive group work sessions as part of the curriculum This study aims to explore whether the additional guidance and experiences of these junior doctor role models enriches students' understanding and appreciation of the SR by providing a realistic vision of where the learners will be in several years. It has been shown that students "want to hear from 'real' professionals, not archetypes" (GMC, 2018, "Make the over-riding message[…]", para. 1) and in doing so can better develop coping strategies.

Methods
The SR was performed as a compulsory group work activity for the entire cohort of 83 second year medical students on the MBChB programme. This is a multicultural group with age ranging from 18 to over 40 and the percentage of international students was 42%. Students complete one afternoon every week in a clinical setting. The students were introduced to the concept of SRs in the lecture theatre, based on the Point of Care foundation guidance, and were briefed about the topics for the facilitated rounds to follow: To reduce group sizes, the cohort was evenly split into two separate rounds held in parallel. Each group had a presenting panel of three doctors consisting of two CEs, one being the lead facilitator, and a consultant. The consultants introduced discussions about each topic in turn. The two CEs then shared their own personal anecdotes and challenges with the student audience and afterwards invited the students to share any experiences from their own early clinical exposure. CEs facilitated the discussion by reflecting on their experiences as new doctors and recent years at medical school. This discussion was aided by CEs also being present in the audience to help encourage the students to voice opinions and thoughts.
The students were given a feedback form asking them to evaluate the Point of Care Foundation outcomes (The Point of Care Foundation, 2014), using a 5-part Likert scale (completely disagree to completely agree), and to supply in white spaces how they thought the Round had impacted on specific aspects of their professional identity. The qualitative data was coded by two authors and then a brief thematic analysis was performed.

Statistical analysis
Data was anonymized by a senior faculty member. Statistical analyses were carried out using IBM SPSS version 20.

Students' performance in the Schwartz Center Round:
Of the 83 students in the cohort, 82 returned the questionnaire following the SR; 71 answered all questions and 21 gave written feedback. This represents an 86% completion rate with 25% providing written feedback. Written commentary could be grouped into the following five categories: -Professionalism as a binary entity -Unable to relate -Attention-seeking and an opportunity to complain -Sharing and empathising in a safe space -Learning from others' experiences Most students gave positive feedback about the perceived benefits of the rounds, with no students responding negatively in all 5 themes.
Students who gain understanding and engagement with the Schwartz Center Round are more likely to reap the benefits of the Round regarding working relationship skills and enhanced patientcentredness The success of raising understanding of and engagement with the SR was addressed by the three criteria: (i) "greater understanding of how expressing thoughts, expressions and feelings can help me"; (ii) giving and receiving support is beneficial and helps us all"; and (iii) greater awareness in handling sensitive issues". Pearson correlation coefficient analysis shows a strong positive correlation (P < 0.001) between the responses to each of these questions and the responses to those designed to analyse SR effectiveness in enhancing students' working relationship awareness and skills. These were: (i) "work better with my colleagues"; (ii) "gained confidence in handling non-clinical aspects of care"; and (iii) "greater awareness of improving teamwork, connectedness and communication.
Likewise, the students whose experience of the SR raised their understanding and engagement also had a strong positive correlation with those self-reporting an enhanced patient-centredness. This criterion was assessed with the following four questions: (i) "greater awareness of the importance of attentiveness to social and emotional aspects of patient care"; (ii) "awareness of increased feelings of compassion towards patients"; (iii) "greater understanding of the importance of empathy with patients as people"; and (iv) "gained knowledge that will help care for patients".

Attitudes to SR based on responses to questionnaires:
Of the 21 students who provided written feedback in the questionnaires, the following 5 themes were identified:

Professionalism as a binary entity
Themes from the written feedback suggested that some students felt that professionalism, compassion and empathy were either qualities that you 'have' or 'don't have,' suggesting they do not consider them values that can be developed or improved upon. The students commented that: "I hope that I already am professional, understanding and tolerant" (student 10), we "should already feel compassion" (student 18) and "those who have the insight to know they have been affected emotionally by a situation will already seek help and advice from people they trust or those professionally employed to assist them." (student 8).

Unable to relate
A few students appeared to find it difficult to see the value in sharing experiences, seeming to understand the purpose of the SR but perhaps not the relevance to them, or what to do with this information; "I just feel like they were telling stories from their time in hospital but I did not see how that would affect how I act around my colleagues" (student 2), I "gained understanding, but didn't find it completely effective" (student 6) and the "stories were very vague, not very to the point" (student 13).

Attention-seeking and an opportunity to complain
Two students found some views particularly difficult to connect with, describing attention-seeking behaviours amongst their peers and suggesting that the SRs are a platform to promote a culture of complaining. They noted: "people wanted to talk about themselves and it sort of turned into a complaints session … people just try to come up with more extreme stories and how they were victimised" (student 10) or "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. Facilitated whinging session" (student 8).

Sharing and empathising in a safe space
Conversely, several students described the SR as promoting shared empathy, providing a space to explore emotions safely and express thoughts, questions and feelings; "I have learned to empathise better with my colleagues…I learned what might go on in other peoples' minds" (student 3) and "understand the usefulness of the rounds and the importance of speaking up" (student 1), 'understood that others feel similar to me" (student 12) and "I would feel more confident to speak up about how I feel" (student 5).

Learning from others' experiences
Many students reflected on the SR as a tool to hear colleagues' experiences and how they dealt with sensitive issues. One student stated that "hearing others' experiences has prepared me for potentially difficult situations" (student 14) and another learned "how to deal with adverse reactions and situations and about duty of candour" (student 12). Two students directly commented on the input of CEs mentioning that "Clinical educators had useful past experiences" (student 15) and that "advice was given to guide us in approaching different situations which was somewhat useful" (student 1). Students felt it was "useful to share others' experiences" (student 16) and "learnt stories from colleagues" (student 19) including "How to handle racism and inappropriate comments (student 12). One student "learnt emotional regulation techniques" (student 3).

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 selfaware 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 selfaggrandisement 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.

Conclusions
SRs are an effective way of fostering empathy and understanding towards patients and colleagues in the healthcare environment. When piloted among second-year medical students, though some felt their colleagues were exploiting the exercise to complain, most students felt it would improve their patient care, teamwork and communication skills. There is some evidence that the inclusion of CEs made the SR feel more pertinent to the students with the junior doctors' clinical experiences being described as a useful addition to the discussion. Suggestions for future research include assessing students' self-perceived empathy skills and whether they feel this is something that can be developed through practise. Using objective measures of empathy before and after an SR may also be useful to determine if students' empathy skills improve with these early interventions.
Abbreviations SR, Schwartz Center Round

Declarations
This study was conducted in accordance to, and with the approval of, the Ethical Review Board for the Schools of Science and Medicine, University of Buckingham. All co-operating individuals gave their consent for their responses to be published.
All data is available on request from the corresponding author.
All authors declare no competing interests.
Funding was provided by the School of Medicine, University of Buckingham.