A realist informed mixed methods evaluation of Schwartz Center Rounds® in England

Creating a composite definition of Rounds

Literature was screened to remove duplicate definitions (e.g. the same definition in multiple publications) to avoid ‘double counting’. Text describing Rounds (what they were and their aims, e.g. structure and purpose, as well as any text describing what they were ‘not’) was extracted. The text was analysed thematically by four team members independently (Michelle Hope, CT, JM and ML), core concepts were discussed and agreed, and a single definition was produced. The face validity of the definition was confirmed after review by members of the study advisory and steering groups (with expertise in Rounds/well-being interventions in health care).

Evidence base for Rounds

For empirical papers, data were extracted on standard features (authors, setting, aims, design/methodology, measures and findings). Quality assessment of qualitative and quantitative primary studies was undertaken using the tools developed by Jones et al. ,17 which include an assessment of the key criteria and then an overall rating (high, no or few flaws; moderate, some flaws; low, significant flaws). Mixed-methods studies were, in addition, assessed against the six criteria for good reporting of mixed-methods studies developed by O’Cathain et al. 14 Their quality was rated as low (< 3 criteria were met), moderate (3 or 4 criteria were met) or high (≥ 5 criteria were met).

Composite definition of Rounds

The definition arising from thematic synthesis is:

Schwartz Rounds are the signature programme of the Schwartz Center for Compassionate Care. They provide a regular (usually monthly) open forum (drop-in rather than by invitation) for multidisciplinary clinical and non-clinical staff at all positions within the health-care organisation to come together in an environment that is safe and confidential. They provide staff with a level playing field to reflect on, explore and tell stories about the difficult, challenging and rewarding experiences they face when delivering patient care, and receive the support of their colleagues. Rounds are typically organised and managed by a steering group, championed by a senior doctor/clinician. They last for 1 hour and are often held during lunch periods (with food provided). They are a group intervention within which multiple perspectives on a theme, scenario or patient case (i.e. their stories) are briefly presented by a pre-arranged and pre-prepared panel and then opened to the audience for group reflection and discussion, usually facilitated by a senior doctor and psychosocial practitioner. The focus is on the non-clinical aspects (e.g. psychosocial, ethical and emotional issues) surrounding the patient–caregiver relationship – thereby addressing a wide range of important topics rarely discussed elsewhere – and the attendees are encouraged to be open and honest, and reflect, discuss and explore their experiences thoughts and feelings. The interaction between the panellists and audience is felt to foster insight and support from colleagues, create a sense of working in a supportive environment and lead to improved relationships and communication within the hospital hierarchy, improved communication and teamwork between staff and patients and among staff, improved well-being of staff including enhanced resilience, improved compassionate care and ultimately impact on organisational culture.

Definition from Taylor et al. 7 This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/

Some sources explicitly articulated what Rounds were not. This included that aims were distinct from traditional clinical/grand rounds; that stories and discussions should not focus on the patient, their diagnosis or plan of care; that Rounds should not be used for problem-solving or to determine what could be learned clinically; and that they were not intended to produce actionable outputs.

Identification of alternative interventions to include in the review

Our prime aim was to identify interventions that aim to help support health professionals with the emotional challenges of delivering patient care. At the outset we identified some aspects of Rounds that we felt were fundamental to the intervention (i.e. hypothesised programme resources offered by the intervention) and that our informed choices regarding ‘alternative’ interventions. This included providing an opportunity for reflection and disclosure, and offering psychological safety. Other inclusion criteria included that interventions needed to focus on the psychological (as opposed to the physical) well-being of staff; be person directed (vs. work directed); and provide primarily emotional rather than cognitive/clinical support (thus, for example, excluding mortality/morbidity meetings that aim to provide lessons in terms of cognitive errors or systems issues). Although Schwartz Rounds are a ‘group’ (rather than an individual) intervention, we chose not to limit alternative interventions by this characteristic because of the importance of reflection and/or disclosure as a key potential mechanism in Rounds that is shared by other, non-group-based interventions. Existing reviews of psychological/emotional support interventions for clinical staff were used to identify alternative interventions. 31–34 Consultation with the PSG and advisory group led to the inclusion of other interventions (including action learning sets, restorative supervision, reflective practice groups, Balint groups and critical incident stress debriefing). A total of 11 alternative interventions were included (see Table 3).

Search strategy

Following the scoping literature review methodology outlined by Arksey and O’Malley,16 the search strategy involved three components: (1) a database search, (2) internet searches and (3) consultation with experts. To be included, evaluations of interventions had to (1) have a health professional sample (either qualified or trainee) and (2) evaluate the intervention using qualitative and/or quantitative methods. The review excluded non-English-language sources, unpublished dissertations or theses and any records not accessible via the methods stated below. Searches were from inception to 2015; all searches were conducted between 14 October 2014 and 5 February 2015, using the same databases as for the Schwartz review (see Appendix 3).

All records were pooled in a bibliographic database. First, records were screened to exclude duplicate entries. Second, the title and abstract of remaining records were reviewed for eligibility. Three attempts were made to access the full texts of papers: (1) university online library, (2) Google Scholar™ (Google, Inc., Mountain View, CA, USA) and (3) journal website. If the full texts were unavailable through these sources, then the papers were excluded.

Charting the data

The data from the included papers were extracted into a spreadsheet that included standard items to describe the paper (e.g. citation, country, setting, population/sample and overall design) and the evaluation [e.g. length of evaluation, data collection method(s), outcome measures and key findings]. In addition, items were developed that were specific to each intervention, for example whether the intervention was group or individual focused, the size of group, the length/number of sessions, the content of sessions, whether or not the intervention was facilitated and whether or not training was provided for facilitation/supervision. The key findings were examined across all of the included literature and analysed thematically to enable synthesis within, and comparison across, each intervention. This resulted in the identification of three categories regarding outcomes relating to (1) self, (2) others (e.g. patients and colleagues) or (3) organisational level (see Report Supplementary Material 3).

Quality appraisal

A quality assessment of each paper was conducted as described in Evidence base for Rounds.

Synthesis

A detailed descriptive summary of each intervention was produced, which included a narrative description of the intervention [including the number of participants, the original setting and health-care setting(s), and the intended aims/outcomes], the number and type of included papers, the variability in intervention (fidelity to original format), a synthesis of the main findings across papers, and the overall quality of the evidence base. See Table 3 for a summary description of each intervention and see Report Supplementary Material 3 for other information.

Comparing alternative interventions with Rounds

To compare each intervention with Rounds, it was necessary first to define the key features of Rounds. The composite definition of Rounds, and features that were explicitly ‘not’ part of Rounds, underpinned this. Each descriptive feature in the definition was extracted into a table, together with the features that were ‘not’ part of Rounds. Further clarification was added for some descriptive features to ensure clarity of meaning (e.g. ‘reflection’ became ‘provides an explicit opportunity for reflection’), which became the basis for comparison with other interventions (see Tables 4 and 5). The intended outcomes within the composite definition were not included in the comparisons owing to their broad nature and, therefore, lack of discriminatory power. The completed table was shared with the study advisory and steering groups to test the face validity of the ratings.

Rounds versus alternative interventions: comparative features

In comparison with the alternative interventions, Rounds offer a unique organisation-wide ‘all-staff’ open forum to share stories about the emotional impact of providing patient care (Tables 4 and 5). Although many of the other interventions expect ‘open, honest communication’ as a key feature, and provide an explicit opportunity for reflection, none is open to all staff (e.g. clinical and non-clinical, voluntary attendance), and many are not ongoing programmes but are instead one-off training courses or events. Some of the training interventions (e.g. mindfulness-based stress reduction or resilience training) are multidisciplinary, but the intended outcome is practice of the skills learned, and so is individual based rather than group based.

Other key aspects in which Rounds are distinct from the alternative interventions relate to what Rounds are intentionally ‘not’ meant to be. In particular, discussions within Rounds should not ‘problem solve’, whereas problem-solving/action-planning are key features of many of the other interventions (e.g. action learning sets, after-action reviews, critical incident stress debriefing). Most of the alternative interventions also offered flexibility in format, compared with the contractual licence (with stipulated conditions) required for running Rounds.

Arguably the closest types of interventions to Rounds are Balint groups (albeit rooted in unidisciplinary primary care with closed membership) and reflective practice groups (again generally closed membership and can be unidisciplinary). In particular, both are ongoing group programmes in which challenging/rewarding experiences about delivering patient care are shared and discussions are facilitated, and both provide the opportunity to give and/or receive peer support in safe and confidential environments. However, neither offers an organisation-wide opportunity for staff to attend, and both would have an expectation that members/attenders would contribute, whereas in Rounds, attenders can choose to be silent listeners.

Disclosure

Disclosure is the action of making new information known. In psychological terms, it is the ‘social sharing of emotion’. 39 Two main theorists on the psychological aspects of disclosure are Rimé and Pennebaker. Rimé and colleagues39–41 have focused on how individuals socially share emotions with others following an emotional event, and the effects of this on emotional recovery. Pennebaker and colleagues35,42–44 have focused on the effects of disclosure of emotional events on physical and psychological health.

Emotion is an essential aspect of describing trauma. People experience greater health benefits if they share emotions and thoughts surrounding trauma than if they share facts;42,45 using language to label an emotion/experience creates a structure, which facilitates understanding of the event. 43 Similarly, Lepore et al. ’s46 ‘completion hypothesis’ states that putting one’s experiences into language allows individuals to impose a narrative around it, making it comprehensible to themselves and others. Conversely, actively inhibiting thoughts and feelings ‘gradually undermines the body’s defences’ (p. 2),35 which leads to reduced physical well-being. Confronting significant events helps us understand and assimilate the event, which improves physical and emotional well-being. 35

Of all emotions, people are least likely to share feelings of guilt or shame. 39 Non-disclosure is associated with the anticipation of negative interpersonal responses to disclosure (e.g. labelling or judging). 47 The benefits of disclosure vary according to the listener’s response to it. 45,48 Nils and Rimé48 identified two responses: the empathic mode buffers emotional distress temporarily (the individual feels better) and the reframing mode leads to emotional recovery (the individual’s basic assumptions are positively modified). However, when disclosure of events is invalidated, any benefits may be diluted. 46

Safe environment

A safe emotional environment is important for group work, reflection and disclosure. Emotional safety is achieved in attached relationships where there is openness, vulnerability and trust. Emotional safety at work derives primarily from the experience of feeling valued, accepted, recognised and respected. 49

Emotional safety is one element that generates a sense of community,50 where it is safe to tell the ‘truth’, requiring community empathy, understanding and caring. Boundaries – or containment – ensure that the group is ‘purposeful, bounded and safe’. 51 Effective leaders (in Rounds this means clinical leads and facilitators) are necessary to construct these conditions. Another element necessary to develop a community is a sense of belonging.

Psychological safety ‘is a shared belief that the team is safe for interpersonal risk taking’. 52 In psychologically safe teams, members feel accepted and respected and think less about the potential negative consequences of expressing themselves. Leaders increase psychological safety by empowering members of the group to participate, and in collaboratively addressing concerns. With psychological safety there is a ‘sense of confidence that the team will not embarrass, reject or punish someone for speaking up’. 52

Reflection

Reflection is a ‘generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciation’ (p. 3). 53 Theories of reflection suggest that it is a structured learning activity in which questions are answered and knowledge is created36,54,55 and argue that reflection is a rational act, and although emotion is a trigger or catalyst for reflection, its role is limited.

More recently, psychologists and sociologists including Lazarus,56 Mezirow57 and Goleman58 have argued that emotion plays a central role throughout the reflective process and that emotion cannot be separated from learning. Emotional intelligence is said to be highly complementary to reflective practice;58 individuals need to understand not only themselves, but also others, and their feelings and empathy are key to emotional intelligence and important to reflective practice. 59 For a person to ‘grow’, an environment is required that provides genuineness (openness and self-disclosure), acceptance (being seen with unconditional positive regard) and empathy (being listened to and understood). 60

Barriers to reflection can be practical (e.g. finding the time,55 location) and/or psychological (e.g. fear of judgement, criticism). The timing of reflective practice is crucial, especially in relation to stressful/tense experiences. A review soon after an incident is deemed ‘hot’ (emotive): it is subjective and influenced by emotions. Reviews held later are ‘cold’: emotions have cooled and the reflective practice is clearer, more balanced and objective, which leads to improved reflections. 61 Ixer62 suggests that individuals need non-judgemental support; they need to feel ‘safe’; they need a role model (e.g. a mentor who reflects on their own practice); they need opportunities for reflection; and they need time and energy. 63

Social support and group work

Social support is the perception and actuality that you are cared for, that you have assistance available from other people and that you are part of a supportive social network; ‘group work provides a context in which individuals help each other and can enable individuals and groups to influence and change personal, group, organisation and community problems’ (p. 8). 38

Social support is associated with psychological well-being in the workplace and is hypothesised to work by having either a buffering effect (where it moderates an outcome) or a direct effect (leading directly to something). 65,66 Karasek’s65 job–demands–control model is a ‘buffering model’, as work social support (such as support from colleagues and supervisors) is said to buffer against job demands/lack of control, thereby protecting mental and physical health. 67,68

Social exchange theory details the negotiated exchanges between people (tangible and intangible) as more or less rewarding or costly. 69 Cost could be the effort put into a relationship (e.g. time). Rewards include elements of the relationship that have positive value (e.g. acceptance, support and companionship). Social exchange involves a connection and trust with another and brings satisfaction when people receive fair returns for their expenditures. The effort–reward imbalance is associated with poor health functioning.

Group work is the opportunity to reflect on, and learn from, the nature of the group interaction itself. The group context and group process is explicitly utilised as a mechanism of change by developing, exploring and examining interactions within the group. A number of therapeutic factors that facilitate group work include universality, altruism, instillation of hope, cohesiveness, catharsis, interpersonal learning and self-understanding. 37

Analysis

The interviews with key stakeholders and observations of Rounds were analysed separately, before the main data collection and analysis of case studies in phase 2. A semistructured interview schedule (see Appendix 7) was developed to describe and explore participants’ experience of developing and/or running Schwartz Rounds in the USA. Each interview was transcribed by a professional transcription service and analysed using a thematic analysis approach, following the key stages of data familiarisation, data reduction and interpretation.

Key findings

From the visit, we identified some guiding principles underlying Rounds:

1. they were a way of teaching caregivers to be compassionate and that compassion could be taught

2. they needed to be inclusive and multidisciplinary

3. they needed to be structured in a way that would encourage doctors to attend

4. they needed to be structured and have a format with a topic and a panel, to focus on the non-medical aspects of care and to not be a forum for problem-solving

5. they needed to have support from organisation’s leadership (including attendance) to make visible the organisation’s values that connecting with patients and supporting staff is important

6. the space created needed to be non-judgemental and safe to encourage people to speak and share their experiences and to protect panel members and participants from any bullying behaviour that could arise from sharing their experiences

7. the role of the moderator was important and they needed to create a safe space and show vulnerability.

These principles informed our initial programme theory (see Chapter 8) and led to the research team reflecting and theorising about fidelity and adaptation issues, and identifying and testing which aspects of Rounds could be considered (i.e. core and adaptable periphery components in phase 2 case studies). 70

Secondary data

Secondary data for the 115 providers in England (at 15 July 2015) were collated from the PoCF, NHS Digital (www.hscic.gov.uk), Hospice UK (www.hospiceuk.org) and provider websites. These included the date of adoption of Rounds, their location, and the size and type of provider. When available, data were extracted for each provider from the NHS staff and patient surveys, and from the Care Quality Commission (CQC) (see Appendix 9 for further details).

Online survey

Questions were developed by the project team (with input from advisory and steering group members) to capture details of implementation of Rounds. The survey comprised seven sections with between 45 and 84 questions, covering preparation for implementation, how Rounds had been implemented (e.g. frequency of Rounds, typical attendance numbers and staff groups, how Rounds are publicised) and the resources/costs (staff and non-staff) incurred (see Appendix 10 for the survey). The survey was managed via Qualtrics (an online survey program; Provo, UT, USA; www.qualtrics.com). A survey link was e-mailed to all consenting participants (with reminders 10 and 20 days after the initial invitation).

Telephone interviews

Semistructured telephone interviews, lasting between 30 and 60 minutes, covered how Rounds were introduced, organised and run; and respondents’ views on their impact, and sustainability (see Appendix 11 for the interview schedule). Interviews were digitally recorded, saved to a password-protected network drive and transcribed for analysis (except one for which notes were recorded by hand). Interview data were also used in staff experiences and realist evaluation chapters (see Chapters 6 and 8).

Survey and interview data were collected between January and August 2015.

Secondary data

Descriptive statistics were used to describe the profiles of the Rounds organisations (including the type of service provider and location). We examined the timing of adoption of Rounds and categorised each site according to the categories of adopters described by Rogers71 in his ‘diffusion of innovation’ theory: innovators (first 2.5%), early adopters (next 13.5%), early majority (next 34%), late majority (next 34%) and laggards (final 16%) (see also Robert et al. 1). Inferential statistics were applied to compare adopters and non-adopters, and Rounds sites in different adoption categories, in relation to the three quality of care indicators, for all providers for which such data were available (see Appendix 9). Statistical significance was set at a p-value of < 0.05.

Survey

Data were examined for completeness and anomalies, and free-text responses were recategorised into existing or new categories when appropriate. It was necessary to exclude some providers from certain analyses, either because they were very early adopters (e.g. thereby preceding the PoCF licence/support package) or because they were very recent adopters (and thereby not able to provide reliable data about, for example, the frequency of Rounds). All quantitative data were analysed descriptively, initially as a total sample and then according to type of provider (e.g. NHS trust vs. hospice) and size of provider (small, < 2000 staff; medium, 2000–4999 staff; large, ≥ 5000 staff) using cross-tabulations. Cases were removed listwise if responses were missing. Free-text responses that could not be categorised were analysed thematically. Costs data were analysed as follows: average catering costs were divided by the mode attendance figure to give an average cost per person. Staff costs were calculated from the Agenda for Change (AfC) bands/staff grades provided and based on the hourly rates for hospital-based health-care staff provided by the Personal Social Services Research Unit. 72 Staff costs are based on 21 providers (seven small, seven medium and seven large) that gave complete data for their administrator(s), facilitator(s) and clinical lead(s), unless otherwise stated.

All quantitative analyses (secondary and survey) were conducted using SPSS (Statistical Product and Service Solutions) (version 22.0, 2013; IBM SPSS Statistics, Armonk, NY, USA).

Interviews

The interviews were analysed using a framework approach to organise the data around key topics addressed in the interview and themes that emerged from respondents’ accounts of their experiences of Rounds73,74 both inductively and deductively (e.g. reasons for adoption were analysed according to the six attributes of an innovation argued to predict adoption from Rogers’71 diffusion of innovation model). Four research team members familiarised themselves with the interview transcripts and contributed to the iterative process of clarifying, refining and elaborating themes. Our aim was to provide a rich picture of the diversity of practice, experiences and views in relation to running Rounds; to highlight the challenges faced and adaptations made by organisations; and to identify possible patterns and associations in the data. Matrices were developed to summarise and enable review of the data for each theme (akin to Gale et al. 75).

Types of organisations

The majority of sites in England were acute, community or mental health trusts (n = 86, 75%), followed by hospices (n = 25, 22%), with the remaining sites a prison, a university medical school, a private hospital and an ambulance trust. The adoption of Rounds varied by type of organisation, with, by July 2015, nearly half of all acute trusts in England adopting Rounds (68/155, 44%); 26% of mental health/learning disability trusts adopting Rounds (15/57) and 18% of community trusts adopting Rounds (3/17). An estimated 13% (25/197) of organisations offering hospice care had adopted Rounds.

Year of implementation

There was a sharp increase in the implementation of Rounds in England between 2013 and 2015, coinciding with the publication of report of the Mid Staffordshire inquiry (Francis report)3 in February 2013, which mentioned Schwartz Rounds (Figure 5). This rate appeared to have slowed in 2016.

FIGURE 5.

Implementation of Rounds: number of new providers running their first Round per year (to December 2016; n = 154). Figure excludes providers outside England (n = 10) and ‘other’ providers (n = 5) including an ambulance trust, three medical schools and a private hospital. LD, learning disability.

How did staff first hear about Rounds?

Respondents were most likely to have heard about Rounds through recommendation from an internal colleague or peer (n = 25, 60%), followed by an external colleague/peer (n = 8, 19%), via research about support mechanisms for staff, and by attending a Round elsewhere (both n = 7, 17%). Other sources included other training courses or programmes (e.g. at The King’s Fund or NHS Leadership Academy), newspaper reports and Hospice UK.

Reasons for adopting Rounds

Explanations for adopting Rounds often referred to the need to focus on staff well-being and support as the key to improving patient care, slightly different from the stated intention of Rounds developers, that Rounds were an innovation to teach compassion and strengthen patient–caregiver relationships (see Chapters 2 and 7):

We identified [. . .] there was a gap around if you like the emotional side of support for staff [. . .] filling that gap in a way that we thought would be both beneficial and supportive [. . .] the format is that it gives a safe environment for people to raise, discuss, reflect on the emotions and pressures of caring.

Tyne-172-Clinical-Lead

Most interviewees cited the emotional well-being of staff as an important motive for adopting Rounds, but some participants mentioned organisational reasons, with Rounds as a vehicle for culture change being important:

We did a specific piece of work looking at the (organisational) culture and the attitude of staff towards each other and so this [Schwartz] kind of came as a change-management-type intervention following a specific piece of work. [. . .] it came off the back of an investigation into kind of a bullying culture [. . .] and we had a steering group and from that came this idea of introducing Schwartz regularly.

Esk-123-Clinical-Lead

I think when you want to have cultural change in any organisation you’re looking at a drip effect. And so if you want to eradicate some of the harsher and more judgemental ways of dealing with people [. . .] and the subscript of Schwartz is, don’t punish people, support them [. . .] and changing the culture or improving the culture making us a place that people want to work, despite the hard work and despite, you know, the resource issues.

Axe-389-Facilitator

Although the increase in the uptake of Rounds in 2013/14 might suggest that providers were responding to the Francis report,3 we found little evidence of this, although the report may have proved a catalyst. Our analysis using Rogers’ Diffusion of Innovation model71 suggests that, initially (2009–13), adoption was driven by ‘passive spread’ through informal communication, whereas following the Francis report, more active processes – led by the PoCF with planned, targeted dissemination, advocacy from opinion leaders and a perceived need to be seen to be addressing staff well-being – led to more active adoption. More recent adopters were also influenced by the provision of funding (e.g. from charities such as Macmillan, Hospice UK, and LETBs). 1 Report Supplementary Material 4 summarises the data according to the attributes argued to predict adoption: relative advantage, compatibility, complexity, trialability, observability and reinvention.

Preparation for implementing Rounds

As per PoCF guidance (see Report Supplementary Material 5), nearly all providers had attended Rounds in other sites (n = 35/41), with early pilot sites visiting Boston. Most had utilised facilitator training (after April 2013; n = 31) and/or accessed mentorship (n = 31). One respondent recommended attending Rounds in other sites as preparation:

Visit Rounds, go see them, get your key people in to come and see them. They are hard to describe. You need to go witness [. . .] be there and feel the hairs rise on the back of your neck when you hear the stories.

Ash-400-Facilitator

Attending a steering group meeting or speaking to a facilitator or clinical lead in another organisation was reported by half (n = 21), and a similar number had attended an introductory talk at the PoCF (n = 18). Other preparatory activities included having planning and preparation meetings (n = 38), and marketing activities such as articles in staff newsletters (n = 31) or launch events (n = 7). A few organisations (n = 12) organised additional training for facilitators. Having organisational board support is a contractual condition for running Rounds; in addition, one provider reported giving presentations to ‘lots of senior management groups’ to inform them about Rounds. A facilitator at one acute trust reflected on the importance of board support:

You’ve got to have the board in on this. [. . .] I don’t expect the chief executive to come; he’s very busy but we need someone at that level of seniority [. . .] to advertise the fact that they give this activity their approval and blessing [. . .]. I think without that you can’t get going.

Thames-199-Clinical-Lead

Organisational structure for Rounds

Rounds require a clinical lead, at least one facilitator and an administrator, together with a steering group (recommended to be 8–12 members from across the organisation for larger organisations; see Report Supplementary Material 5). All organisations had at least one clinical lead and facilitator, but some (n = 4) did not have dedicated administrative support. Interview respondents reinforced the importance of having adequate administrative support:

Make sure that you’ve got adequate resources and support [. . .] it needs to have some finances attached to it so that you’ve got some admin[istrative] support [. . .] so that somebody can develop your posters and your flyers to get out there advertising the event. Somebody who can co-ordinate organising the lunch for the day [. . .] checking out that the room’s ready and prepared for people coming and then collecting in the paperwork and getting it sent back to the Point of Care.

Clyde-361-Facilitator

The PoCF states that it helps if facilitators have experience of group work and managing difficult emotions, and that often facilitators have psychological or social work backgrounds. Of the 37 Rounds providers that gave details, 20 (54%) had at least one psychologist/counsellor/psychotherapist as a facilitator, and 8 out of 37 (22%) had social workers or allied health professionals (AHPs) (mostly art therapists). Others included doctors, nurses, chaplains/spiritual leads and managers. Of the 35 Rounds providers that provided data about their clinical lead, 30 (86%) had a senior doctor (medical director/consultant); others included nurses, psychologists and psychotherapists.

A key theme from the interviews was the importance of finding the ‘right’ people for the clinical lead and facilitator roles, who had sufficient commitment and enthusiasm for Rounds, the appropriate skills and the time to plan and prepare Rounds thoroughly: ‘I think the passion has got to show, you have to be passionate about it for it to succeed’ (Tay-127-Clinical Lead). Several respondents specified that facilitation skills were preferable to psychological training, and others recommended establishing a group of facilitators:

Get a team of facilitators together so it doesn’t rely on just one or two members of staff. Because if you get illness or somebody moves on to another position then the entire safety of the Rounds hinges on maybe just one or two people and that just doesn’t feel safe really.

Looe-381-Facilitator

One-third of providers reported that their steering group met monthly as recommended by PoCF (n = 14), but a number reported meeting less frequently, for example quarterly (n = 6) or every 6–8 weeks (n = 5). In two providers, the steering group met twice per month (both before and after each Round). In 40% of organisations (n = 19), the steering group reported directly to its board. Many interview respondents spoke about the importance of the steering group composition, suggesting that this was less about size and more about ensuring that there were sufficient ‘champions’ to spread the word about Rounds and supporting the ‘core team’ to plan Rounds and, in particular, to identify panellists (see also Chapter 6). Diverse steering groups were generally favoured and enthusiastic self-selected members were preferred. Including senior members of the organisation was felt to be important as they could use their authority, visibility, ‘reach’ and ‘clout’ to support clinical leads and facilitators to establish and sustain Rounds:

It does help to have somebody higher up in the organisation, like [senior nurse] [. . .] It’s a bit difficult sometimes [. . .] for the clinical lead and the facilitator to go out there and recruit people [. . .] Somebody a bit further up, in some ways has a bit more clout [. . .] [to] open doors a bit more [. . .] So she can go in and say to people, ‘Look, could your area look at providing somebody for the Schwartz Rounds?’ and I think that’s worked.

Tiber-151-Clinical-Lead

The frequency, timing and scheduling of Rounds

Organisations are contractually obliged to run a minimum of six Rounds per year in hospices and nine in ‘larger’ organisations (e.g. NHS trusts). Of the 20 providers that had run Rounds for ≥ 1 year at the time of survey completion, two of the 16 NHS trusts did not meet this criterion (running them every second or third month, with one site explaining in the interview that running them monthly had been too onerous); all four hospices were running Rounds at least six times per year. Most NHS trust providers that had been running Rounds for < 1 year at survey completion (2013/14) intended to run at least nine, with most aiming for 10; and all six hospices intended to run at least six (with half intending to hold 10–12 per year).

From the interviews it became apparent that 10 Rounds per year was felt to be feasible as it enabled ‘monthly’ Rounds while avoiding holiday periods (e.g. summer or Christmas). One outlier was a mental health/learning disabilities trust that reported running 26 Rounds per year. Here Rounds were run monthly simultaneously across multiple sites owing to the trust being geographically spread. One-third of organisations (n = 14) reported rotating the location of Rounds across multiple (up to five) sites in their organisation. This was more common in NHS trusts (n = 12, 39%) than in hospices (n = 2, 20%), the latter tending to have only one site. Apart from the core Rounds team, it was rare for staff to travel between sites to attend Rounds, and therefore in these providers most staff could attend Rounds only every 2–3 months when one was held where they worked.

Interviews revealed that most organisations spent time trialling different days and times before determining what ‘worked’ best, acknowledging that whenever Rounds were held, some groups of staff would be excluded (see also Chapter 6). Most organisations ran Rounds at lunchtime (n = 30), although some ran Rounds in the afternoon (n = 5) and six providers varied the time of Rounds rather than having a typical time in order to enable wider accessibility across staff groups. Nineteen providers varied the day of the week for Rounds, although one provider reported that it had tried this but decided that having a fixed day and time was preferable.

Publicising Rounds

Regardless of trends in attendance or the length of time running Rounds, interview respondents saw promoting Rounds as key to drawing in an audience, and interview and survey data showed that significant time was dedicated to this, as it was felt to be fundamental to Rounds’ sustainability:

Well you have to [spend lots of time on publicity]. If you don’t do that it goes away.

Chess-388-Facilitator

Most organisations followed PoCF guidance on using multiple approaches to publicise Rounds, and some had access to communications expertise/resources. Most commonly this included posters (93%, n = 38) and e-mails (90%, n = 37). Two-thirds of sites publicised Rounds in staff communications such as newsletters (n = 29) or discussed them at internal meetings (n = 29). In one organisation, the chief executive included Rounds in his weekly blog. Others reported using the intranet (n = 5) and word of mouth (n = 4). Most organisations showed ingenuity in finding ways of drawing attention to Rounds, for example using colourful posters, using the public address system and advertising on screensavers or television screens in staff/reception areas.

Attendance at Rounds

There was considerable variation in the typical attendance figures for Rounds, with the estimated average attendance ranging from 17 to 150 people at NHS trusts, and from 18 to 45 people in hospices (Table 9).

Maintaining or increasing attendance was perceived as crucial to sustaining Rounds and was a concern for most interviewees, who considered achieving ‘good attendance’ (however this was defined) as a key challenge that they faced (see Chapter 6). Survey respondents were asked about trends in attendance over the previous six Rounds. No clear patterns emerged according to the type of organisation or length of time running Rounds: similar proportions of organisations reported that attendance had been ‘about the same’ (41%, n = 16) as those that had reported that it ‘varies each time’ (39%, n = 15). Four organisations reported that attendance had increased over the previous six Rounds, and four reported that it had declined. Concern about attendance was expressed by many, particularly when attendance had declined:

So what we’ve noticed is that the number of attendees is dwindling. In the early days I would say we started with approximately 100 people attending and we’re routinely down to about maybe 30 or 40 now [. . .] So that’s a challenge in itself, the number of attendees.

Looe-381-Facilitator

Another key aspect was the attendance (or not) of specific staff groups. Survey respondents reported that doctors and nurses were represented at Rounds in all providers. However, interviewees reported that this masked the most commonly mentioned under-represented groups: front-line clinical staff, particularly ward nurses and doctors. Other under-represented groups included porters, maintenance and domestic staff, AHPs and board members (see Chapter 6). Most respondents were alert to the structural barriers preventing ward staff attending Rounds but found these difficult to address because of the nature of clinical work and staffing levels:

The biggest challenge really has been getting people from the wards to come because they are so busy. [. . .] I think that’s because we run on quite a thin line of staffing and it’s difficult to release staff.

Neath-327-Facilitator

The importance of senior clinical members of staff and board members attending Rounds was often mentioned in interviews, both to experience Rounds themselves and to demonstrate endorsement of them. Respondents in some organisations claimed good attendance by executive team members but others expressed disappointment that such staff were rarely present (see also Chapter 6).

Non-staff costs

Staff costs

The main staff time associated with Rounds is for administration, facilitation and clinical leadership. There are also costs associated with steering group membership. Steering group sizes ranged from two or three members, plus the core team, to 35 members, but their role, and the regularity and amount of contribution, was highly variable. Costs and time here are therefore presented in relation to the core roles: administration, facilitation and clinical lead (see also Report Supplementary Material 6 for extended version with data tables).

There was wide variability in the total number of hours dedicated to administration, facilitation and clinical lead tasks in Rounds, even taking into account the size of the organisation. Time spent on all roles taken together ranged from 7 hours to 82.15 hours per month, with an average of 24/28 hours (median/mean). Whereas all sites had at least one facilitator and clinical lead, four sites did not have any administrative support (all were NHS trusts).

Owing to the fact that organisations chose to resource Rounds in such variable ways, with blurred boundaries between facilitator and administrator, or between facilitator and clinical lead roles in some organisations, we present the total costs for these three staff roles together. There was a wide range in band/time spent for all three roles, and consequently costs were highly variable (Table 12). However, this indicated that median monthly cost for these roles was approximately £650 (small provider) or £2000 (medium/large providers) (see Report Supplementary Material 6 for details of each role separately).

Reasons for attendance: enablers

Word of mouth was effective in encouraging people to attend Rounds:

I do try to encourage a number of my colleagues to go [. . .] I sometimes think when you see it [the round publicity] [. . .] I didn’t have a clue what that was about [. . .] and I passed it by for a bit. So a bit more explanation under it [the publicity] that you can easily see might capture people’s attention [so they might be persuaded] to go.

Willow-32-Attender

When a topic seemed relevant and resonated with potential audience members, they were more likely to go:

I went to the [name of hospital] one because the topic was relevant to me, which was ‘the hospital at night’. And I wanted to go because I often am here by myself working [. . .] it’s a very intimidating place to be at night for me by myself.

Cherry-71-Attender

The publicity for and titles of Rounds were important influences on whether or not staff attended:

I just saw a poster in the ward, and actually I was saying to someone ‘I can understand why patients feel angry’ and then I said, ‘Oh, maybe I should go to this’.

Juniper-14-Attender

In other examples, a lack of knowledge about Rounds meant that the publicity did not initially engage:

I used to see the Schwartz Round advertised and [. . .] delete the e-mail because it didn’t make sense. The title didn’t really mean very much to me. I get lots of e-mails. Then one day I read it a bit more and I thought ‘oh that sounds really interesting’.

Willow-32-Attender

For many staff, it was not enough to be told about Rounds, or to see publicity, to really understand what Rounds were: they needed to experience them.

Finally, non-clinicians told us that they thought that Rounds were a helpful way of finding out about the experience of clinicians and, as a consequence, they felt more connected to the organisation’s purpose of delivering excellent patient care. Some participants told us that they found witnessing colleagues’ distress in Rounds uncomfortable and that it felt voyeuristic.

Reasons for attendance: barriers

Reasons given for not attending included not understanding what Rounds were and practical difficulties such as location and timing.

A few Rounds attenders whom we spoke to decided that Rounds were not for them, and Rounds attendance was an issue for some staff. Certain groups were more likely to attend than others. Ward-based staff in acute care and community staff, who faced geographical challenges accessing Rounds, struggled to attend Rounds, despite initiatives to address the barriers. Ward nurses, on 12-hour shifts with only two half-hour breaks, lacked the autonomy to make the decision to attend or found it hard to find the time to attend, particularly at lunchtime when patients needed support with meals, unless someone else covered the ward or it was particularly quiet. Even those with autonomy over their work schedule experienced some difficulty, with work pressures being the biggest obstacle to attendance. Some organisations experimented with running Rounds at different times of the day to attract different staff groups. Other strategies included releasing staff to attend Rounds on a rotational basis and prioritising attendance among those who had a personal connection with the case being discussed:

It tends to be quite a lot of senior people that go [. . .] What’s up with one person feeding back at that senior level and getting the girls on the ward [to attend], giving them a little break to go to the Schwartz Round because it’s beneficial for them? It’s good for the health-care assistants, it’s good for the ward clerk, everybody makes a team [. . .] One senior member go, feedback, take it in turn every Schwartz Round, utilise that time to go and cover your member of staff on the ward to free them up, make them feel valued and let them go to the Schwartz Round and hear how good it is.

Sycamore-26-Attender

Staff perceptions of Rounds

Several interviewees were surprised by the extent of audience discussion and involvement, expecting the time to be occupied by formal presentations, or were surprised by their own emotional reaction and that of others.

In terms of Rounds’ structure, many appreciated the ritual and predictability, suggesting that this contributed to feeling safe; audience members valued hearing about the origins and history of Rounds, feeling that this contributed to Rounds’ legitimacy. It was recognised that Rounds needed time to evolve within organisations, especially as audience members became more accustomed to Rounds and the associated behaviours and etiquette.

Participants described Rounds as interesting, engaging and a source of support. Participants valued the opportunity to reflect and process work challenges. Many appreciated the opportunity to learn more about their colleagues, understand their perspectives and motivations, and engage in multidisciplinary interaction. This led to greater understanding, empathy and tolerance towards colleagues and patients. Key themes included:

• contextualising patients and staff

• seeing the person in the professional

• feeling that their experiences are validated and they are not alone

• levelling effect of Rounds

• acknowledging vulnerability (see Chapter 8).

These findings link closely to Chapter 8; thus, here we briefly present these themes, with further data provided in Chapter 8.

Rounds stories provided greater context regarding patients and staff, and attendees described gaining insight into the daily reality of other staff, which helped them recognise that they were united in common efforts to deliver health care. Attendees voiced greater respect and appreciation for colleagues after learning more about their role and had a better understanding of patients’, carers’ and staff’s behaviour, as well as the uncertainty involved in health-care work:

I think it certainly has enabled me to put myself a little bit more in the situation of my patients and think ‘actually what are they going through?’ It enables you to stop and draw on the experience [. . .] and that’s where I think it makes you better because you perhaps get less angry at people’s responses to things and realise that actually there is a lot of emotion involved within these situations and that they’re not just robots that are dealing with a case and it’s never black and white, I think you realise more and more as you listen to these Schwartz Rounds, there’s never a true right or wrong.

Cedar-29-Panellist

Rounds stories allowed staff to see the person in the professional, and corrected misconceptions that they held about individuals, helping staff understand each other’s behaviour, promoting tolerance and greater empathy in times of adversity:

I think it helps me understand other people’s perspectives. [. . .] If I can understand people that means I can feel more empathetic. [. . .] I like to think there’s a lot of understanding and empathy being created within the audience, [which] I hope is undoing some negative psychological processes as well as creating some important ones.

Willow-20-Attender

The majority described how Rounds validated their actions and emotions, helping reduce feelings of isolation. Rounds had a levelling effect by highlighting the reality that all staff groups, regardless of seniority and experience, encountered difficulties:

I find it of huge benefit to know that we are all in this together, that we do not have our heads down in the dust and the dirt pretending everything is all right. That it is OK to speak and say it is a really shocking environment that we work in and that we are all pushed to our limits on many occasions, affecting all aspects of our work. It makes us feel very uncomfortable because you want to give good care [. . .] and also [. . .] the target-driven nature of things [. . .] that human interaction with the patients [and] relatives has a tendency to go. [. . .] I just find [. . .] every meeting is enriching and a nourishment to one’s soul and psyche that [. . .] we can talk about it.

Kennett-155-Clinical-Lead

Rounds attenders were impressed by their colleagues’ honesty, especially those who showed vulnerability. Many felt that this was countercultural to the NHS mentality of appearing resilient at all times and was all the more notable when recognised in a public forum. Hearing senior colleagues express vulnerability, emotion and regret was said to be powerful and connecting and to provide role models. Such knowledge supported participants in the realisation that no one is infallible, acquitting many of unrealistic expectations. Awareness that all staff encounter difficulties in the emotional, social and ethical aspects of their work contributed to feelings of relief. Interviewees told how Rounds had been educational in helping them understand situations more fully and not as ‘black and white’, and promoting coping strategies to help them manage difficult situations.

Factors influencing whether or not audience members speak at Rounds

Audience members spoke when they had experienced a similar situation, when they felt that panel members would benefit from their contribution, when they wanted to provide moral support, and when they wanted their story ‘heard’. Some contributed only when they had sufficient authority on the topic and deliberately held back to allow colleagues an opportunity:

I’m not a person who says a lot, but I’ve probably [spoken] once [or] twice [if] there’s a topic or an area [that] I have an opinion or an experience [in and] that I feel is probably good to share with the audience.

Cedar-9-Attender

Others spoke in support of colleagues on the panel or the facilitator to keep the Round safe; some were reluctant to show emotions publicly, and the presence of a line manager prevented some contributing. Other reasons why audience members did not speak in Rounds included a lack of confidence, not having a connection with the case, and a reluctance to engage with a contentious topic.

Round attendance outcomes

Motivations for presenting

Reasons given for agreeing to be panellists included professional development, increasing visibility and their own or team’s profile, seeking closure on a difficult situation, showing appreciation towards colleagues, sharing knowledge and helping others learn from their experiences. Panellists reported wanting to process a difficult clinical experience and said that they felt a sense of achievement after receiving positive audience feedback. Some respondents valued the opportunity to say thank you to colleagues publicly. In established Rounds sites, audience members were more likely to volunteer to be a panellist or suggest that their team might be willing, and learnt what makes a good Schwartz Round case or topic: ‘often people say “oh this is definitely going to be a Schwartz Round” ’ (Cedar-28-Panellist).

Panellists also described utilising Rounds to share experiences to enable learning, especially when the topic was associated with a misunderstanding or a lack of action:

I wanted to share that experience because I know that mental illness is quite stigmatised still in medical profession especially with colleagues in sort of A&E [accident and emergency] departments [. . .] I thought it would be a good opportunity to put it out there that if you’re frustrated, angry, scared and confused with our patients, we feel it as well sometimes.

Willow-29-Panellist

Panellists’ experiences of Rounds’ stages

Panellists described their experiences of Rounds’ stages: ‘sourcing stories and panellists’, ‘panel preparation’ and ‘telling stories to trigger reflection and resonance in Rounds’ (Figure 6; see Report Supplementary Material 7 for a summary of these stages).

FIGURE 6.

Stages of Rounds.

Overall experiences

Facilitators perceived Rounds facilitation as a great responsibility, wanting to ‘get it right’ and feeling quite daunted by the whole experience. Facilitators were keen to make it safe for staff to share experiences, and to gain the audience’s acceptance and participation while maintaining control. Facilitators spoke of the courage needed to stand at the front of the room and ‘carry the Round’: ‘initially it’s completely scary in case you put your foot in it and fall flat on your face’ (Ash-400-Facilitator).

There were also some apprehensions that the Round discussion might not ‘work’ or be appreciated by staff, especially when Rounds were new to an organisation:

I was hoping it went well. It felt good. The evaluations were positive. I was just nervous because I was prepared as much as I could be and then realised as soon as we got to the audience bit I had no control.

Willow-16-Facilitator

Over time, many concerns decreased as facilitators’ confidence and experience increased.

Some held the joint role of clinical lead and facilitator. Key responsibilities of the clinical lead included spreading the word about Rounds and supporting the facilitator and steering group in finding and developing stories, and encouraging their medical colleagues to attend, as identified in the PoCF handbook. Clinical lead involvement varied across sites (see Chapter 7).

A lack of capacity to offer support before the Round, owing to other work commitments, was a challenge that the majority of clinical leads acknowledged and that meant that they could not support or release the facilitator from the Rounds’ associated task of panel preparation. Another downside of having missed panel preparation was the potential for clinical leads to be emotionally affected by the panellists’ stories during the Round:

I have to say [the facilitator] does all the [laborious work], all the preparation. I have tried to be present to prepare a few of the panel members, but it’s only been a handful and fortunately they appreciate how busy I am and they just prepare the panels and I just pitch up often. Which sometimes means that I haven’t heard the panel stories before and I get a bit hijacked by the emotions sometimes, because I’m hearing the stories fresh for the first time.

Mulberry-168-Clinical-Lead

As with other key Rounds roles, clinical leads described giving over and above the formal resource allocation for Rounds. Despite their efforts, this still limited the amount of support they could offer, which contributed to feelings of guilt and/or a lack of preparedness for some. Clinical leads highlighted the impact that Rounds involvement had had on their practice:

It’s always a bit of time pressure fitting in the panel work and fitting in the Schwartz Rounds. There have been times where I’ve had to delay the start of my clinic because I’ve got a Schwartz Round steering group. But then that’s outweighed by the positive benefits of learning so much from attending the Schwartz Rounds and reflecting on your own practice and resonating with the case. So I think the positives outweigh the negatives.

Willow-178-Clinical-Lead

I don’t have the opportunity to particularly clear my desk, clear my morning either before or after the Round [. . .] One day I went from the Schwartz Round straight into my performance meeting [. . .] And it’s really interesting in my head to compare the hour or so in the Schwartz Round which is a very compassionate, kind, listening environment to the very aggressive, unforgiving environment of my performance meeting.

Mulberry-168-Clinical-Lead

(See Chapter 8, Countercultural/third space for staff for more about contrasting culture.)

Motivation and rewards

Facilitators and clinical leads were often important champions, motivating others to be involved and helping bring Rounds to their organisation. They were highly motivated and had a strong belief in Rounds and their importance in supporting staff in the difficulties they faced in their work. Facilitators described their personal reasons for being involved. These included a perceived alignment between the objectives of Rounds and the facilitator’s values, such as a professional interest in employee engagement and/or reflective practice. Interviewees reported that facilitating Rounds was a privilege, a pleasure and enjoyable, and gave them satisfaction:

As a facilitator, you have that wonderful, very privileged position of seeing both audience and panel, you can see everybody, and it’s just watching people’s reactions as they listen to stories, as they pluck up the courage to put their hand up and participate. It’s quite nice for you to see it flourish.

Tay-127-Clinical-Lead

Facilitators found it rewarding when staff engaged in the discussion. Some considered this an indication of success:

It gives me a buzz when you see that people have really engaged with an issue and that it had some kind of impact on them, whether that’s about them feeling much better supported or perhaps it’s about them feeling better equipped to deal with a similar situation.

Ash-05-Facilitator

Being a facilitator was described as a challenging, rewarding and career-enhancing experience that brought new skills and confidence, which was good for personal and professional development:

I think it’s been a fantastic experience for me. I hadn’t done anything like this before [. . .] I’ve got more confident in helping facilitate Rounds. Initially, I remember feeling absolutely petrified, thinking how are we going to keep going. I still do that to a certain extent because I’m not in my comfort zone, so actually I think doing something out of your comfort zone is actually incredibly rewarding, especially when people are positive about it.

Elderberry-324-Facilitator

Facilitators felt that Rounds had caused them to reconsider the wider implications of their actions and behaviours, especially when interacting with patients and relatives:

I think they [Rounds] make me more reflective as a clinical practitioner. So I’m much more tuned in to how the patient might be feeling, how their family might be feeling and [so I] don’t concentrate so much on the medicine but think about the bigger picture and probably practise more holistically.

Willow-178-Clinical-Lead

Facilitators also described how their involvement had made them more visible and created new connections:

You’re no longer invisible and it has been absolutely lovely forming connections with people who I’d have never got to meet otherwise and hearing about their work and hearing what they do and that has been wonderful.

Ash-400-Facilitator

Challenges

The challenges associated with facilitating Rounds included emotional and psychological concerns, a lack of time and support for Rounds, and pressure to make Rounds a success. For example, facilitators described concerns about keeping Rounds safe and their dilemmas about when and how far to intervene. Some deliberately held back in their facilitation, feeling that they did not always have the permission to step in, as Rounds, although having therapeutic benefits, were not a therapeutic intervention. Addressing the important issues while not taking the discussion ‘too far’ was a challenge. For example, a lack of expertise or experience concerning the content of the Round discussion was a factor that might prevent some facilitators from intervening when needed, yet a reluctance to engage in deeper emotional discussions regarding issues that happen in the workplace might prevent Rounds reaching their full potential:

If something was presented as a risk or issues of malpractice that would worry me because that’s where my clinical expertise is lacking and so I wouldn’t feel comfortable facilitating because I don’t deal with those situations routinely.

Willow-16-Facilitator

Facilitators were very mindful of not wanting to push panellists too far and cause distress, and they were alert to providing emotional safety and containment (see Chapter 8).

Facilitators’ background, experience, skills, knowledge and training

The national variation in facilitator backgrounds has been illustrated (see Chapter 4 and Report Supplementary Material 6). In our nine in-depth case study sites (see Table 2), we interviewed facilitators who were psychologists, chaplains, nurse specialists, social workers, therapists, counsellors and administrators.

Interviewees suggested that psychologists were well suited to the facilitation task and could be good role models:

I do think psychologists make brilliant facilitators. And I come away from the Rounds where I see particularly psychologist facilitators and think ‘oh wow you just knocked my socks off with how you’ve done that. I couldn’t even aspire to be as good as you’. So I wouldn’t necessarily include myself in that, but really, really impressed with psychologists as facilitators.

Why do psychologists make such good facilitators?

I don’t think they’re fazed by it. I think they’re really good at picking different people, they’re really good at modelling that it’s OK to sit with the discomfort, with things aren’t as we would like them to be, [. . .] with the silence, to not to rush in and try and fix it.

In our focus group with mentors, it was felt important for facilitators to have group work and facilitation skills, with their background seen as less important:

I don’t think that you have to be a psychologist or have done any formal psychotherapeutic training, but I do think you need those skills and how you develop them could be in a range of different ways.

Focus group-Participant 03-22.11.16

A facilitation style combining technical skills with a knowledge of group and psychotherapeutic processes informed this interviewee’s facilitation of Rounds:

I have been trained as an action learning facilitator so I know how to facilitate [. . .] the discipline of timing your introduction, timing your main discussions. I’m also trained as a systemic psychotherapist so I know that questions have different meanings and enlist different responses [. . .] and I suppose [I have] the technical skills of questioning and listening.

Sycamore-02-Facilitator

Facilitators from more established Rounds sites had expertise and insights gained from facilitating their own Rounds and sometimes from providing mentorship to facilitators in other organisations. In our case studies, seven facilitators acted as PoCF mentors to new sites. As part of the PoCF mentorship and training scheme, facilitators were encouraged to engage in peer observation, and being a mentor had other benefits:

I’ve had the advantage to being [able to see Rounds run in other sites], so seeing how it’s being done elsewhere and that works really well [. . .] So just being exposed to them, seeing lots and lots of Rounds has been my training.

Ash-400-Facilitator

Facilitators’ passion, understanding and belief in Rounds

As shown in Chapter 6, facilitators often take on responsibility for ensuring that Rounds run each month and for the bulk of time-consuming tasks. This requires facilitators who are highly motivated and passionate advocates for Rounds, and for the majority of facilitators their deep-rooted commitment and belief in the benefits of Rounds was evident. Many had championed Rounds and been instrumental in getting them introduced into their organisation. On most occasions, facilitators volunteered for the role and were often asked because they were already frequent attenders or were Rounds champions (see Chapter 6); however, we found one exception:

When I started my post they said ‘oh, you’ll be involved in the Rounds’, so I didn’t feel like I had very much choice in it.

Horse-chestnut-10-Facilitator

Facilitators’ passion for Rounds was hard to sustain when facilitators felt unsupported and overburdened. We noted a degree of burnout in a few for whom the high initial enthusiasm and drive had been unsustainable, as this quotation illustrates:

So I think what’s wrong in my view is that we are prioritising doing so many things, let’s do this, let’s do this target, this to be met and everyone is running around, and there’s lots of urgent and important stuff to do all the time [. . .] And then no wonder then your own enthusiasm dies after some time and I have to say my enthusiasm has gone down and I’m not going to blame anyone else, but it’s just like ‘what’s the point, we don’t have a venue, we tried doing this, we haven’t got enough support’ [. . .] after 2 years I really didn’t want to continue it.

Willow-177-Facilitator

(See Chapters 4 and 6 for more exploration of facilitator burden and sustainability issues.)

Facilitator and clinical lead style

Good facilitation involves ensuring fidelity to the Schwartz Rounds model (see Fidelity to the Schwartz Rounds model). The core component of fidelity, ‘focusing on emotional impact on staff, the non-medical aspects of work’, was mentioned by all facilitator interviewees, particularly the issue of discouraging ‘problem-solving’. Taking action to address this was said to require a level of tact and discretion, as facilitators attempted to carefully move the discussion away from problem-solving and towards reflection, without appearing to reprimand and discourage participants from participating again:

[After telling his/her story the panellist said] ‘I really want your help now with how I sort out this problem’. So [the panellist] made an invitation to problem solve and [the facilitator] beautifully turned it around [. . .] she turned it into an invitation to reflect.

Ash-400-Facilitator

Another interviewee shared their opinion on what style of facilitation did not work and thereby created a less safe environment:

It was far too much putting people on the spot, too controlling, too much trying to pull out information. [. . .] They weren’t relaxed enough to let it flow and the discussion to evolve [. . .] they jumped in too quickly, is what people were saying, shut us down [. . .] it felt like people who were often moving into problem solving were jumped on and it felt like, they may have felt very slapped, slapped down in terms of their contribution. And again that just makes it feel unsafe if that happens.

No ID (anonymised to fully protect identity)

Co-facilitation was usual, and part of the ‘facilitation’ core component of fidelity to the Schwartz Rounds model (see below). All of the facilitators we interviewed saw it as desirable to have two facilitators, because facilitating Rounds successfully and maintaining safety in the group was deemed onerous and difficult for one facilitator to do alone. Those who had attempted it (in an emergency) told of how scary and difficult it was and how they would seek to avoid repeating the experience (see Chapter 8, Trust, safety and containment). Interviewees acknowledged that this working relationship was most successful when both parties had complementary skills, offsetting mutual limitations and enhancing mutual strengths, explaining that successful co-facilitation was promoted by:

Being explicitly interactional with my co-facilitator. So doing the reflecting about how we use our roles and how we use our different characteristics to play to our strengths.

Willow-01-Facilitator

The distinction between the role and the style of the facilitator and clinical lead is further explored in Chapter 6, Facilitators’ and clinical leads’ experiences.

Facilitators’ and clinical leads’ reputation, credibility, seniority and networks

One of the core components of fidelity is having a senior clinical lead (see Fidelity to the Schwartz Rounds model). We found that clinical leads varied in their level of seniority and their ability to provide organisational intelligence on the most complex, challenging, topical and interesting cases, incidents or issues facing the whole organisation. For instance, the clinical lead in some sites was a medical director (Cedar, Sycamore and Cherry) or a nursing director (Elderberry and Sycamore), whereas in the remaining four out of nine sites the clinical lead was a medical consultant. Clinical leads whose seniority resulted in them working across the whole organisation and with staff on the front line, as well as those in middle, senior and executive-level management positions, heard about suitable cases and topics more readily than consultants whose everyday work was limited to a particular specialty. For instance:

Being a [divisional director] certainly keeps me in touch with many colleagues. We’ve just been talking a few minutes ago about a serious incident that occurred 18 months ago in the hospital. So I’ve become aware of issues like that which may cause an emotional reaction in the staff looking after their patients. So there are times when I think well perhaps that’s a topic we could discuss in the Schwartz Round, if the team are comfortable with that. So I think that role helps me communicate and hear in a formal and informal way what’s going on.

Sycamore-03-Clinical-Lead

Some facilitators and clinical leads had worked in a staff support and well-being capacity, so they brought that source of personal credibility and trustworthiness (Cedar and Ash). When facilitators were new to their organisations, they had to work harder to establish this personal credibility and trustworthiness, and found it harder to source stories because they had little organisational intelligence, they knew fewer people and fewer people knew them, so stories were not brought to their attention in the same way as in more established sites with well-known facilitators. Others felt disadvantaged by not having such access to these sources because their role did not involve working across departments and wards:

So I often couldn’t come up with, there’s the stand-out patient or family that everyone’s talking about and they will notice on the ward and someone will usually say, ‘I think that would be really good for a Schwartz Round’? Well, I wouldn’t come across those stories, so that hampers me.

Elderberry-02-Facilitator

Organisational factors

The sampling criteria for our case study sample are outlined in Chapter 2.

Time running Rounds

One criterion on which we purposively sampled case study sites was the length of time running Rounds. Of our nine in-depth case studies:

• four commenced Rounds before the end of 2012 (Ash, Cedar, Elderberry and Horse-chestnut)

• two commenced rounds between January 2013 and the start of our study (1 September 2014) (Willow and Sycamore)

• three commenced Rounds during our study (after 1 September 2014) (Mulberry, Juniper and Cherry).

Over time, we expected facilitators to become more skilled with experience, and Rounds would take time to become known and embedded. We had not anticipated the cumulative impact of multiple Rounds in other ways.

An analysis of our case study data suggested that, over time, each Round has a cumulative impact on the next, building capacity and developing and deepening the community resource that Rounds provide and enable to have effects. We previously presented a linear ‘three-stage’ diagram (see Figure 6 and Chapter 6). A further analysis of our case study data revealed this cycle to have an additional stage alluded to in terms of outcomes in Chapter 6 (stage 4: a range of post-Round after-effects), and also revealed the cyclical nature of the four stages (Figure 7). Stages 3 and 4 of one Round, or a series of Rounds, have an impact on the early stages of the next Round/Rounds.

FIGURE 7.

Cumulative impact of stages of Rounds.

When further comparing sites new to running Rounds with more established sites, we have noticed differences in (1) audience ‘Schwartz savviness’, (2) audience trust and confidence and (3) facilitator confidence.

Audience characteristics

Rounds characteristics

The stories presented could be either theme or case based (see Chapter 8). Facilitators stated that often when they set up Rounds these tended to be more theme based, rather than case based, as theme-based Rounds were easier to prepare for, and cases were often more difficult to find (see Appendix 21):

It has tended to be that most people have been prepped individually and then put together around themes. So we’ve had one clinical case [. . .] come forward, which is quite interesting in a trust that’s full of clinical cases, people feel a bit more comfortable talking about themes at the moment.

Cherry-01-Facilitator

A few facilitators talked about case-based Rounds being more powerful than theme-based Rounds:

So, although we could get issues, they [. . .] weren’t the ones that made your hair stand up on the back of your neck. So they were more of the thematic ones which I think start to lose a bit of their power if they’re just those. So we were struggling to get more of the case-related issues because it was falling more to me to do them.

Can you say a little bit more about the thematic Rounds not being so powerful?

Well sometimes they work, sometimes they don’t, [. . .] but we were getting health-care [scientists], somebody from pathology sharing their story and whilst that may be very powerful, it probably has less immediacy, less of a life-and-death issue.

Observing multiple Rounds across different settings, we noticed familiar themes being discussed in our case study sites: ‘compassionate care’, ‘population specific’, ‘challenging topics and themes’, ‘challenging families and patients’, ‘staff-focused’, ‘organisation focused’, ‘safety’ and ‘upbeat and general’ Rounds. The topics that staff brought to Rounds reflected the increasingly complex and challenging health-care environment in which they work, and we were struck by the universality of some of the topics (see Appendix 21).

Trust, safety and containment

Our data suggest that key to the successful implementation of Rounds is the concept of trust and safety (Box 5). This is important in all three initial Rounds stages: selecting the story or theme, the panel preparation and the Round itself (see Figure 10). Participants’ feelings of trust, safety and containment develop throughout the stages of a Round and intensify and are reinforced over time, through constant repetition and reinforcement for subsequent Rounds. Safety in Rounds means a space where panellists and audience members feel accepted, respected and valued. Facilitators ensure psychological safety through the use of ground rules including confidentiality and anonymity, through providing non-judgemental support, through the use of the Schwartz model to provide a bounded and established time and through the use of the routine and rituals of Rounds. Conversely, an ‘unsafe’ Round would include panellists and audience members experiencing embarrassment, rejection, reprisal or blame, or experiencing bullying and punishment for speaking out. Thus, in Rounds where safety may have been compromised, this can have a damaging impact on participants’ feelings of trust, safety and containment and, thus, on their willingness to attend, participate and disclose.

We had not fully appreciated the importance of trust and containment as a mechanism in the implementation of Rounds at the beginning of our study, despite ‘safe and non-judgmental space’ being in our original programme theory. However, through our interviews and observation it became clear that in order for people to feel confident to speak, to allow themselves to be vulnerable and to share their stories, emotional safety (held and supported largely by the facilitator/clinical lead), which includes the concept of ‘containment’, allows trust to develop in audience and panel members, thereby facilitating open and honest dialogue. The aim is to allow panellists and attenders to express and explore feelings that may feel too shameful or painful to be shared with others; theory suggests that it is through this process that attenders learn to cope with those damaging, overwhelming or potentially explosive emotions. 90

Aspects of safety noted by our panellists, audience members and facilitator interviewees included pre-Round safety checks, such as checking that panellists understand the potential consequences of publicly telling their story and countering the ‘urge to confess’, ground rules on confidentiality stated at the start of every Round, and a signed agreement regarding confidentiality when attenders sign in.

Group interaction

This CMO configuration (Box 6) primarily relates to the Round itself (i.e. stage 3) and only relates to some panel preparation meetings (stage 2), as some are conducted one to one and not in a group. Our initial programme theory identified that it was important to have a range of attendees in a multidisciplinary group of health-care staff but did not identify which aspects of this would be an important mechanism.

Our data analysis has unpacked this mechanism further, highlighting the importance of sharing stories and reflecting as a group activity. Reflection can often be an individual introspective process with little insight into the similar experiences of others. Rounds as a group process of interaction provide an opportunity to trigger reflection in others through hearing stories and hearing others ‘reflect on action’, triggering resonance and reflection in individuals. Individuals are able to achieve higher levels of learning and retain more information when they work in a group rather than individually. 94

The experience of listening to the stories of others and sharing stories underpins Rounds, creating a group intervention in which staff can feel heard and supported, and are exposed to the experiences of others. This gives the potential for Rounds to be a ‘richer’ intervention than one-to-one reflective sessions or supervision, and we suggest that the group interaction element of Rounds is an important prerequisite for other CMO configurations. Drawing on theory, we identified six factors that add to the experiences of Rounds participants because it is a group intervention: (1) cohesiveness, (2) universality, (3) shared values and motivation, (4) catharsis, (5) interpersonal learning and (6) self-understanding. 37 Being in a group can help participants learn factual information from others and how to share personal feelings, show concern, and support others through a modelling process, observing and imitating the facilitator, clinical lead, panellist and audience. 37

The resources offered by Rounds being a group intervention included the recognition of shared experiences and feelings (reaction); insights into others’ experiences and how they connect everyone; and the acknowledgement of the contribution and work of less visible, non-clinical staff. Interviewees identified the importance of the multidisciplinarity of the group, the flattened hierarchy and the opportunity to think and learn from each other (see Report Supplementary Material 11 for more supporting data):

I think the very big difference [between Rounds and one-to-one supervision] is, particularly in a big organisation like this, is that there is no other forum that’s multidisciplinary and there is no other forum where no matter where you are in the staff hierarchy you are empowered, if you wish to take it, to have a voice, I think that’s the hugest difference.

Mulberry-367-Facilitator

All in it together and it’s kind of ‘oh I didn’t know it was like that for you’. I think it strengthens the connections and the relationships with other people [. . .] it’s this kind of shared experience around challenges, making change or dealing with loss or feeling stressed by your work, whatever it might be.

Ash-400-Facilitator

Countercultural/third space for staff

The countercultural and third-space mechanism of Rounds was not explicitly in our original programme theory, but our data and recent literature shifted our thinking. In late 2016, a book by the former lead mentor for Rounds in the UK, Barbara Wren, was published in which she wrote: ‘the process of Schwartz Round implementation is in many ways counter-cultural. Good Rounds shift an organisation and its workers away from their default position of urgent action, reaction and problem solving to an hour of stillness and slowness’ (p. 41). 95 Our data supported this and helped us to identify the countercultural nature of Rounds as a key mechanism: albeit as a group-level mechanism. The countercultural/third-space environment is a mechanism but also over time becomes the resource and context for the other CMO configurations, as outlined above: storytelling and self-disclosure and reflection and resonance sit within this third space (see Figure 10). The third space is a resource provided/offered and co-created by participants to enable other mechanisms to ‘fire’ (Box 7).

We drew on and tested our findings regarding Rounds being a countercultural space in relation to third-space theory. First and second spaces are two different spatial groupings where people interact physically and socially, such as home (everyday knowledge) and school (academic knowledge). Third spaces are the in-between, or hybrid, spaces, where the first and second spaces work together to generate a new third space96,97 to create a hybrid culture and identity because respite is needed from any challenges to functioning in the second space. 96,98

We identified nine aspects of ‘third space’ in the literature98 and tested if these ‘fitted’ well with Schwartz Rounds in focus group interviews with mentors. Participants agreed with items 1–6, and less so with items 7–9:

1. free – third spaces also generally offer food and drink, the staples of socialising

2. neutral ground

3. leveller

4. conversation is the main activity

5. easy to access and accommodating

6. cadre of regulars

7. low profile*

8. playful*

9. home away from home.*

Items marked by asterisks were felt by some not to fit so well with Rounds, but one facilitator felt that Rounds were low profile in that by their countercultural nature they could be ‘under the radar’ of the organisation’; and that they could at times be fun and playful, and certainly that a ‘home away from home’ atmosphere was strived for, although it was recognised that this was different from the examples in the literature, such as coffee shops.

One aspect that does relate to other third spaces such as coffee shops is the provision of food (which is in the PoCF contract, is symbolic of community and ‘breaking bread together’, and is also somewhat countercultural). Our data suggest that Rounds are third spaces where staff can connect with their values and humanity, with the first and second spaces being (1) professional/role identification and values (everyday work) and (2) NHS/organisation (imposed work practices) spaces. 99 Third space offered four applications for our work on Rounds:

1. recognised space, in which professionals could ‘hang the confusion and chaos’99 of the workplace for a time while they thought through their practice100

2. community space, creating a community of commitment101 and a community of creation102 not centred around targets, objectives and rational negotiations about how goals can be achieved, but on ‘what people care about and want’ to create together103

3. conversational space, for dialogue between participants that is safe, secure and supportive, space that ‘stands in between’ the formal areas of practice104

4. learning space –

places of transition, and sometimes transformation, where the individual experiences some kind of shift or reorientation in their life world [. . .] [where] a shift in identity or role perception [occurs] so that issues and concerns are seen and heard in new and different ways.

Savin-Baden, pp. 8–9105

Wren95 suggests that:

by keeping connected to the three overlapping contexts of the patient, the staff member and the organisation, without a requirement to produce an outcome for any of them, Rounds can create a space within which the triangulation of healthcare experience can be both noticed and resisted.

Wren, pp. 44–595

For example:

It would be the factors from the reflections on the Rounds for me [. . .], the reflection that we do as a team on our practice [. . .] just helping me to be better at being compassionate and understanding and open to people recognising the impact on ourselves emotionally. And just that greater resilience.

Ash-05-Facilitator

Others suggested that there had been wider cultural changes (‘ripple’ effects) through changed conversations in organisations, which had been facilitated by the countercultural third space offered by Rounds:

It’s sort of softened the ground for things to grow, the kind of conversations that [a colleague] has with the medics and the different clinicians that are very different to the ones that she was having about a year ago [. . .]. The actual human effect, the empathetic affect of what happens when you’re caring for staff.

Carmel-385-Facilitator

Staff spoke about ‘leaving things at the door’ and being in a different ‘zone’ that provided a headspace to reflect. This creates behaviour change by providing an opportunity to do things differently; the honesty, without judgement or fear of any backlash, that was provided in this space was the power of Rounds:

To hear doctors being very honest about a difficult patient and how they handled it. I’d never heard this in this building and I’ve been around 49 years and it was the honesty of it without judgement and I think that was the powerful thing that got to me.

Cedar-04-Panellist-frequent attender

Uncluttered headspace to a certain extent, communal headspace as well, where people can take that hour where you can put the brakes on, you can stop, you can leave that constant drive for performance targets at the door and have that clarity where you can just breathe and start thinking with like-minded colleagues who experience the same pressures where we’re at, where the difficulties are and, kind of, reflect on those [. . .] being able to sit with the emotion, be with the emotion, that you normally just press, push it down, push it down, push it down, move to the next task, [. . .] so, that ability to reflect on your practice and have that headspace I guess when you walking out of the Round and you go back to your clinical practice, that’s where that opportunity to do things differently comes from.

Horse-chestnut-07-Clinical-Lead

Rounds provided a confidential space that was counter to the prevailing culture in health-care organisations in the following ways:

• flattened hierarchy

• staff experience valued

• emotional disclosure encouraged

• stillness

• resisting outcomes

• revealing and discussing own emotional needs and vulnerability (vs. the myth that this is undesirable for health-care professionals or a sign of weakness)

• support and listen to each other without judgement

• attending to own emotional needs rather than those of patients

• slow reflective space with some silence (see Report Supplementary Material 11 for supporting data).

This resulted in staff being able to be honest, and in revealing emotions being more culturally acceptable.

Self-disclosure

Self-disclosure is the process of sharing information about yourself with another person (or people). Disclosing the human aspects of staff’s work – the social, emotional and ethical issues that they face in their professional lives – is a key element of Rounds. Self-disclosure was part of our original programme theory, but our data shed light on the ways in which it is a key Schwartz mechanism: as part of sharing stories and prompting others to reflect and self-disclose, allowing stronger relationships and trust to develop (Box 8).

Psychological theory suggests that emotional self-disclosure makes individuals ‘transparent’ and vulnerable to others. 106 The greater the depth of the discussions, the more likely the person is to feel vulnerable. Therefore, trust built over time among the disclosers (often a panellist or an audience member) and the facilitator/audience is essential to reach deep discussion.

Social penetration theory proposes that, as relationships develop, interpersonal communication moves from relatively shallow, superficial levels to deeper, more familiar ones. 107 Disclosure reciprocity is when a panellist reveals personal information of a certain intimacy level, and another panellist or audience member will in turn disclose information of the same intimacy level, creating a sense of emotional equity. 108 Disclosure is particularly beneficial in helping people come to terms with chaotic and unexplained events. Empirical evidence suggests that ‘opening up’ and expressing stress-related thoughts and feelings is associated with improved physical and mental health. 44 Theory also suggests that sharing fears and problems (as well as good news) with others who are trustworthy and supportive plays a key role in mental health109 and can reduce stress. 110 After mutual self-disclosures (as in Rounds) people can feel a boost in positive feelings111 and build relationships with friends and coworkers,112 and emotional, not factual self-disclosures can lead to closeness as long as disclosers feel that listeners are understanding and accepting,113 which links to the importance of good preparation and to the CMO of trust, emotional safety and containment, described earlier in the report.

In sharing information about themselves, people make choices about what to share and with whom to share it. Our data suggest that coming to a different ‘third space’ (see Countercultural/third space for staff) allows people to share and self-disclose in ways that they would not elsewhere, so that they come into the room as a person and not only as a professional. Some suggest that this enables barriers to come down and allows them to ‘share from the heart’:

Outside of Schwartz Rounds people tend not to share as much, for whatever reason [. . .] it’s often the most junior members of staff that set the ball rolling with deep sharing, such as the health-care assistants for example. They share from the heart and I just wonder whether it’s the actual humanity where you’ve taken your professional badge or hat off, metaphorically speaking obviously, that you come in as a person and I think the subject themes guide that in many ways because it allows you just to be vulnerable, to share about a time or an experience in your life and I just think that really just maybe energises others to feel safe [. . .] I think we just connect with that human sense of caring [. . .] and I think it’s maybe that it just pulls down so many barriers that people and I think [. . .] there’s some connection or some energy I think that it generates in the room.

Elderberry-11-Panellist-and-Steering-Group-Member

An outcome of this is connecting staff back to their own humanity and the ‘human sense of caring’, connecting staff together by ‘pulling down so many barriers’, revealing the person in the professional and connecting staff to their empathy and compassion for self and others (staff, patients and carers). Emotional self-disclosure makes individuals ‘transparent’ and vulnerable to others. The greater the depth of the discussions, the more likely participants are to feel vulnerable. Trust built over time is essential to reach the deep discussion and to provide some catharsis:

And I think it’s often that cascade where people just feel safe. I suppose going to a lovely gathering with people that you feel really comfortable with and you have a good old laugh. That cathartic sense of being together or a cry or a row or whatever it is, but it feels safe to do that and you can recollect and it, the connection and the bond are still there.

Elderberry-11-Panellist-and-Steering-Group-Member

Participants reported that the audience response and acceptance is validating, with a supportive audience helping panellists reframe and see an experience they have ‘held’ for a long time more positively and so make it less stressful and emotionally challenging for them (see Report Supplementary Material 11). A panellist who had been assaulted by a patient reflected:

We started talking about how the patient must have felt, how frightened he must have been [. . .] and I’ve never really had that kind of thoughts about what it would have been like for him [. . .] and [now] that anger has largely gone actually and I felt much more connected to his distress and I was able to get through that anger and, to a certain extent, that hatred for him [. . .] hate is a very, very strong word but if you are insulted or hit or assaulted by a patient sometimes hate is an emotion that it can instil within.

Horse-chestnut-01-Clinical-Lead-speaking-as-a-panellist

Storytelling

Telling a powerful Round story starts with an initial idea for a generic theme (e.g. ‘a patient I’ll never forget’), or a wider organisational incident, event or issue (e.g. ‘the junior doctors’ strike’), or a particular case, team or individual (e.g. ‘making a conscious decision to die’). The mechanism of crafting and telling a powerful story that resonates with others was not initially in our programme theory, yet as we began our interviews and observations we were struck again and again by how moved we were by the stories we heard, how they resonated with us and how so many people spoke of the ‘power of the story’. Storytelling and stories as a trigger for reflection are central to Rounds and therefore emerged as a key element of our revised programme theory (Box 9). Wren95 writes that ‘the story is the engine’ (p. 43) and highlights the importance of the ‘use of story to reveal experience in a prepared and crafted way, which allows the audience to move closer to a positive experience of managed exposure and a gradual acceptance of incompleteness and unfinished business’ (p. 43).

Stories are vehicles for behaviour change and can have longer-term outcomes/ripple effects, such as changes in practice, including changes to resuscitation protocols, and long-term benefits for staff well-being:

It has led to some additional work being done [. . .] In one case it led to the review of a particular protocol. [. . .] We had one particular Round, which was around ‘do not resuscitate’, and I know that that fed into more work being done around procedures and protocols around resuscitation. So, very often, it will feed into the current debates in the trust around whether it’s resuscitation or end-of-life care or, drug safety or whatever.

Axe-389-Facilitator

A colleague e-mailed her boss to say, ‘I have attended a Schwartz Round, don’t you think it’s a good idea if we reintroduce clinical supervision in our practice?’ And, indeed, they reintroduced it, purely because they heard the stories of people going through something, and perhaps they should change. She said, ‘Just to let you know, we’re back to doing this in nursing because of hearing the Schwartz Round,’ so you know, I have a direct example of people actually proactively changing something.

Tay-127-Clinical lead

Other data, detailing outcomes such as support and affirmation, a sense of closure for staff, an opportunity to discuss previously unsaid things leading to some resolution and (positive) impact on teamwork, can be found in Report Supplementary Material 11.

Stories are an effective way to transmit important information and values from one individual or community to the next. Personal and emotionally compelling stories engage more of the brain and are better remembered than simply stating a set of facts, and theory suggests that stories are ‘empathy workhorses’. 114 An effective story captures and holds attention and transports us into the character’s world. ‘Transporting’ is the ‘magic’ that happens when a story holds full emotional and mental attention; we experienced this often in Rounds observation when it felt like everyone in the room was holding their breath and it would have been possible to ‘hear a pin drop’. An example was an organisation’s first Round that was called ‘too young to die’:

We had a really good attendance, we had four panellists who were all really good and had a massive impact. I’m sure you have, but have you ever been in a room where it just goes totally silent? [. . .] And you can feel it? [. . .] We had that [. . .] people talked about it for months after [. . .] we had a wide range of panellists [. . .] and they all told a different story, but really, really, really strong stories, it was brilliant.

Beck-336-Facilitator

Good stories (‘Schwartz gold’) spark and engage through emotions and connect people. Stories were crafted in panel preparation to resonate, ‘paint pictures’ and transport listeners to a scene:

I relived it in my head so I could still remember the person’s room as I was sharing it and although I was picking up eye contact with the audience and kind of, I was kind of back in that person’s room. And even I could hear the clock ticking that he had on his sideboard. I could still hear that when I was passing that onto the audience. Yeah it took me back there and it brought it alive again.

Elderberry-11-Panellist-and-Steering-Group-Member

Our data suggested that the trigger stories were key to Rounds’ success. Respondents seemed to locate the essence of the Round in the emotional experience of the creation of a powerful, positive or rewarding embodied experience for them:

Powerful to be honest, very different stories and I think I don’t know that I was prepared for the outward emotion from the storytellers [. . .] actually witnessing that for real and it’s reliving it even though it was some time ago, you know, that whole outpouring of emotion was quite powerful. And [. . .] it’s the variation in the stories were massive actually. You’ve got clinical director right through to a health-care assistant that’s holding someone’s hand.

Juniper-27-Panellist

When stories ‘transport’, they generate empathy and the brain produces oxytocin, which, when synthesised, makes people more trustworthy, generous, charitable and compassionate, and more sensitive to social cues around them. 114 Stories were important vehicles for reflection:

It was very powerful hearing other people’s stories [it] makes you think about your own practice and how you deliver the care that you deliver [. . .] as well as the bigger picture.

Juniper-27-Panellist

Role-modelling vulnerability

As outlined in Figure 10, ‘role-modelling vulnerability’ is an important aspect of ‘self-disclosure’ and of the countercultural/third space. Revealing, and specifically role modelling, vulnerability is unusual for health-care staff, who rarely show vulnerability in their daily work, and instead display confidence, certainty and invincibility so that they reassure patients and facilitate patients’ confidence in them. Role-modelling vulnerability was identified in our original programme theory, and our data reveal why this aspect is important in how Rounds may ‘work’ (Box 10).

Vulnerability facilitates human connection through the willingness to be present and let ourselves be seen, yet shame gets in the way of authenticity as people become paralysed with fear about what others might see. 115 In health care, Tomlinson116 suggests that public shame and humiliation on ward rounds in medical education gets in the way of honesty or openness for fear of making a mistake or being ridiculed. Brown115 suggests that vulnerability is not a weakness, but it is an emotional risk, and it is the most accurate measurement of courage; shame inhibits connection with others, with people fearful that they are not worthy of it. Being vulnerable allows Rounds participants to connect at the level of their humanity with each other, not as professionals but as fellow human beings. It also demonstrates courage and empowers others to be authentic and vulnerable, creating a circle of connection and allowing staff to be more honest, open and empathetic with each other. Brown117 suggests that shame cannot survive empathy or being spoken about, and that talking about shame ’cuts it off at the knees’ (p. 58117). Our data suggest that good facilitation (supporting emotional safety) can prevent vulnerability turning to shame.

Witnessing peers role modelling courage and bravery creates a level playing field, which breaks down barriers between staff groups and is empowering for others. The language of vulnerability revealed much about how health-care professionals cope in their daily work. Our interviewees spoke of ‘masks’, ‘armour’ and ‘protective shells’ being removed:

It’s interesting to break down some of those barriers of the façade of the consultant, the façade of the surgeon, the façade of the bed manager and actually get to the human being behind the role, because I think that that really puts us on a level which I think is a very healthy place to be [. . .] think that that’s a real leveler within a working environment in a very healthy way [. . .] it’s also a very helpful thing to see the human being behind the mask, so to speak.

Ash-14-Clinical Lead

You are allowed to be a human being and to be vulnerable, and I guess that’s what we were all doing at Schwartz. We were all showing our vulnerability in different ways and . . . being honest about that and not trying to pretend that this stuff doesn’t have an impact, ‘cause it does.

Willow-03-Panellist

The revealing of vulnerability by senior staff in particular was felt to reduce feelings of isolation, and to be empowering, encouraging and supportive to other staff (see Report Supplementary Material 11 for more supporting data).

Contextualising patients and staff

‘Contextualising patients and staff’ is an important aspect of ‘storytelling’ and ‘self-disclosure’ (see Figure 10); it was not in our original programme theory, but we suggest that this CMO illuminates how staff ‘support and teach each other how to better connect with patients (and each other)’ (Boxes 11 and 12). As a result of panellists’ willingness to self-disclose, show their vulnerability and tell their story publicly, audience members and fellow panellists gain an expanded knowledge of patients and staff. They hear multiple perspectives about the same patient from different colleagues, and hear more about the external and contextual factors that impinge on individual patients’ and staff’s decision-making and behaviour. This also gives staff a longitudinal, rather than cross-sectional, perspective of what happened to a patient, which can be particularly important for junior staff/students and colleagues who were involved in one part of a particular patient’s care. In short, they are able ‘to put themselves in the patient’s shoes’ or get a ‘glimpse into the everyday world of that individual staff member’.

Our observation of Rounds provided data to support these insights. For example, after hearing experienced and expert panellist colleagues’ insights into why a patient infected with HIV (human immunodeficiency virus) had not disclosed this to her partner, the initial judgments from a junior colleague changed to a compassionate understanding of the woman’s circumstances and situation, and awe at colleagues’ ability to support the woman to subsequently disclose in a safe way.

Theoretically, the fundamental attribution error supports our understanding of this CMO. Fundamental attribution error is the tendency to explain someone’s behaviour based on internal factors (personality or disposition) while underestimating the influence that external and situational factors and influences have. 118,119 Rounds remind people that others’ behaviour is constrained by situational factors and present an opportunity to take into account behavioural and situational information simultaneously to characterise the actors (patients, carers and staff). Our data suggest that fundamental attribution error applies to contextualising both patients and staff, and we provide separate CMOs for (1) patients and (2) staff.

Interviewees spoke of Rounds providing greater context for their patients’ lives and facilitated greater insight into people’s behaviour, changing perspectives:

I think it’s enabled ‘difficult patients’ or difficult cases to be understood and digested in a more constructive way, in a less defensive way, in a more reflective way. [. . .] but I do think [. . .] that it’s helped people understand the more complex and more challenging cases and why people behave like they do.

Esk-123-Facilitator

Well it’s certainly changed the way I view patients [. . .] I think I’m much more aware of their back story, if that makes sense.

Looe-381-Facilitator)

This allowed staff to step back from challenging and distressing incidents and to ‘walk’ in their patients’ shoes, thereby fostering empathy and changing behaviour:

It makes us think about what we’re doing and we’re walking in their shoes a bit more. I think also you reflect on and you internalise what you’ve heard so even subconsciously you think ‘I might try or do that a bit differently’.

Ash-02-Facilitator

Interviewees spoke movingly of the insights Rounds gave them into colleagues’ worlds and behaviours through the telling of honest, open and powerful stories in which staff revealed their vulnerability; this resulted in attendees feeling more generous towards colleagues and themselves, and having greater tolerance and empathy, resulting in compassion and greater trust (see Report Supplementary Material 11 for further data):

You’re much more sympathetic and tolerant of the decisions other people make [. . .] Rounds are really helpful in reminding [us] that everybody is trying to do their best. [. . .] a more generous understanding of other peoples’ difficulties and how hard everybody is trying [. . .] which makes it easier to be generous to ourselves then as well, in the sense of acknowledging that we do a really hard job.

Taff-138-Clinical-Lead

Hearing more about what the challenges are for us all in our different professions, I think is a useful [. . .] it does make us more tolerant towards each other.

Seine-378-Facilitator

Shining a spotlight on hidden stories and roles

‘Shining a spotlight on hidden stories and roles’ is an important aspect of ‘storytelling’ (see Figure 10), but was not in our original programme theory. We suggest that it illuminates how staff ‘support and teach each other how to better connect with patients (and each other)’ through providing staff with greater insight and understanding of what people’s roles involve, enabling them to learn from each other, foster mutual respect and value a wider range of staff/colleagues, strengthening relationships with other staff, team relationships and spirit (Box 13).

Our data supported the theory that suggests that Rounds enable less visible roles to be made visible, enabling work perceived as routine to be reframed so that what might be seen as background work with low status can potentially be elevated in care work terms. 120 Our data suggested that attendees gained powerful insights into the roles of others, realising that all staff are affected by the challenges of patient care and experience difficult emotional responses. This enables attendees to create and sustain different notions of what the work is and of the person doing the work, because part of the identity-shaping process in ‘job crafting’ is relational. 121 This also enables some staff to connect with the ‘bigger project’ and the purpose of the organisation (caring for and helping patients recover or die well) to others and their values, and reinforces their own values.

By ‘shining a light on hidden roles’, staff reported connecting with each other and feeling less isolated, and we were provided with a concrete ripple effect of staff meeting up who had not done so before (connecting people and reducing isolation):

But in our last Round, we brought a person from A&E [accident and emergency] and a person from the hospital co-ordinator side, and a person from mortuary [. . .] They were talking as if they were on separate planets, not one person knew what the other person was going through, at the very same time, but it was the exact same event [. . .] afterwards, [. . .] I saw them in the corridor and they said, they’ve invited each other for cups of tea, if they’re in in the evening, because they’re all there in the hospital, feeling very isolated [. . .] so these departments are now meeting up for cups of tea every now and then in evening, on the power of realising that, [they felt] isolated that day [. . .] just people realising that they’re not alone, which to me, is a very good impact.

Tay-127-Clinical-Lead

Interviewees spoke of Rounds stories presented by staff they rarely encountered providing new ‘windows into other people’s worlds’, making visible invisible work/workers and giving greater insights into the organisation, allowing staff to feel part of a bigger ‘jigsaw’:

I’ve learnt a great deal about what other colleagues do, but also [. . .] how they see their working worlds [. . .] it’s those windows into other people’s worlds [. . .] for example there’ve been some amazing things that some housekeeping people and facilities have talked about that certainly other people didn’t realise and I didn’t realise [. . .] And then at the other end of the professional spectrum [. . .] the experience of more senior doctors, the consultants, having that ultimate clinical responsibility, and having to give the impression of being sure and confident when actually they feel anything else but that, the weight of that responsibility.

Avon-391-Facilitator

Those whose roles and hidden stories were ‘spotlighted’ spoke of feeling appreciated, supported and valued for their work. Interviewees also spoke of the link between personal stories of health care and organisational life: linking these; making staff visible; shining a spotlight being an exercise in enhancing teamwork; having the opportunity to meet new people at Rounds and put names to faces; and helping staff appreciate and know about each other’s roles much more, resulting in greater understanding and appreciation of their work (see Report Supplementary Material 11 for more supporting data).

Reflection and resonance

Reflection and resonance (situated within the third space CMO; see Figure 10) is triggered as the result of hearing stories and witnessing the self-disclosure of panellists, and as audience members also share their stories and self-disclose, this creates a resource for others (Box 14).

Reflection was in our original programme theory and is the vehicle through which staff make sense of their own and others’ experiences. Resonance was not identified in the original programme theory; however, our data suggest that when the story or experience resonates, reflection is triggered, which can ‘strengthen the carer/patient relationship by providing space to reflect on the cost and impact of caring’ (p. 39). 95 Reflective practice is the process of learning through and from experience to gain new insights of self and/or practice through examining assumptions of everyday practice, being self-aware and critically evaluating their own responses to practice situations. 53,122–124 ‘Reflective practices offer us a way of trying to make sense of the uncertainty in our workplaces and the courage to work competently and ethically at the edge of order and chaos’ (p. 7),125 which resonated with our Rounds data.

Longer-term outcomes and ripple effects included improvements in patient care through recognising the importance of staff well-being and its direct connection to patient care. By sharing and learning from one’s own and others’ mistakes, care can be improved in the future, by embedding a culture of reflection and Rounds that results in recognition of nurses needing more support, leading to a reintroduction of clinical supervision:

Sometimes people do talk about their mistakes and [. . .] that by talking about these things we improve care. [. . .] ultimately one of the cases we can make for why you must continue to fund them is actually well-being for staff, if we’re going to directly impact on helping the patients [. . .] via self-well-being it would improve patient care [. . .] are we well enough to do good patient work?

Focus group-22.11.17-Participant05

Rounds were identified as an important, safe space to offload, think creatively and be challenged, and through this process staff learnt to think back on previous experiences, learn from each other and apply that learning in future encounters with patients:

In terms of my relationships with patients it’s been very helpful to have some time for reflection and I think maybe I would like to think [. . .] that I might try and react differently and try a different approach, whether it be just standing up, leaving the room and shutting the door which I think might be what I try next time and seeing what effect that has.

Juniper-11-Panellist

Many staff suggested that this was the only opportunity for them to have a safe space to reflect and think about ‘tacit knowledge’ in a safe space, which provides a resource to share knowledge and, through that process, has an impact on the practitioner and improves patient care:

I think one of the biggest impacts is [. . .] on the quality of people, patient’s experience [. . .] that space to kind of reflect in a safe space away from the coalface of what is happening, surely has an impact on how good a practitioner someone is [. . .] it gives them a little bit of space to kind of have their reflection in a way which is well structured. Whereas many of us, you know, don’t have any of those things and [. . .] it’s one of the very few learning interventions which has that kind of effect of helping people really gather up and pause and think about actually that tacit knowledge which you don’t get from anywhere else other than those conversations.

Juniper-26-Steering-Group-Member

Interviewees suggested several ways in which this happened: (1) through validating the work they do (we repeatedly heard staff suggesting that what they did ‘was just part of the job’ and ‘not extraordinary’, whereas their colleagues were often humbled and in awe of their practice, validating and supporting through their feedback); (2) through recognising that their experiences and feelings were not unique, and that by talking about their experiences, rather than internalising them, realising that their experiences are shared and are a normal part of the job, which reduces feelings of isolation; and (3) through reflection, allowing them a pause from the busy environment of care work (in a countercultural space), which enables them to be less reactive (see Report Supplementary Material 11 for supporting data).

Emotional safety

Emotional safety is a state achieved in attachment relationships where individuals are open and vulnerable and trust each other. Emotional safety at work derives primarily from the experience of feeling valued: accepted, recognised and respected.

Emotional safety is one element that generates a sense of community. 50 The first task of the community is to make it safe to tell the ‘truth’, which requires community empathy, understanding and caring. Emotional safety cannot be maintained without an ‘authority structure’ to sustain the community: people need to know what to expect from each other in the community. Boundaries make emotional safety possible in terms of logistics (time, place of group, etc.). Boundaries – or containment – ensure that the group is ‘purposeful, bounded and safe’. 51 Effective leaders (in Rounds this means clinical leads and facilitators) are necessary to construct these conditions. Another element necessary to develop a community is a sense of belonging, which includes ‘faith that I will belong’, ‘acceptance’ by the wider community and ‘paying dues’: a sense of belonging, emotional safety, etc., are not achieved without sacrifice or challenge. 50

Psychological safety

Psychological safety ‘is a shared belief that the team is safe for interpersonal risk taking’. 52 In psychologically safe teams, members feel accepted and respected and think less about the potential negative consequences of expressing themselves. Leaders increase psychological safety through participatory management (empowering members of the group to participate) and inclusive management (inclusion of members in collaboratively addressing concerns). 52

Psychological safety is different from ‘group cohesiveness’, as cohesiveness can reduce willingness to disagree and challenge others’ views (i.e. participants are less likely to take risks). With psychological safety there is a ‘sense of confidence that the team will not embarrass, reject or punish someone for speaking up’. 52 This confidence stems from mutual respect and trust among members. Psychological safety goes beyond interpersonal trust: ‘it describes a team climate characterised by interpersonal trust and mutual respect in which people are comfortable being themselves’. 52