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

Phase 1

We undertook two scoping reviews of the literature on Rounds to define Rounds and determine the evidence base, and of other interventions similar to Rounds in order to compare them. 7 We also explored the theoretical literature on reflection, group work and disclosure/discussion of emotional/challenging events to try to identify the mechanisms by which Rounds may work, which helped develop our survey for phase 2 (see Chapter 3), and, together with our interviews with the original architects of Rounds, informed our initial programme theory (see Chapter 8). The methods and findings from the scoping review are reported in detail in Chapter 3 and Taylor et al. 7

We conducted an online cross-sectional survey of all Rounds providers in England that had signed a contract with the PoCF by the start of the project in September 2014 when the mapping phase began (n = 77). We then undertook telephone interviews with Rounds champions (usually facilitators or clinical leads) in the same sample to explore their reasons for adoption and experiences of implementation further. For the collation and analysis of secondary data to map and profile providers running Rounds, the sample comprised all organisations implementing Rounds in the UK by July 2015 (n = 115). We wanted to map the profiles of current UK Rounds provider organisations to determine the reasons for implementation of and, when adopted, attendance at Rounds, and estimate the resource implications of establishing and sustaining Rounds. These data also informed sampling of the case study sites in phase 2. The methods and findings of the survey and telephone interviews are reported in detail in Chapter 4.

Phase 2

Thirteen providers were purposively sampled from phase 1 [to maximise the variation of organisations in terms of size, location and type of provider (acute trusts, hospice, community/mental health care providers)] and length of time running Rounds to provide 10 sites for the longitudinal survey, and nine organisations for the organisational case studies. Six sites participated in both survey and organisational case study components (Table 2). A long list of potential case study sites was drawn up against the sample quota in our protocol while phase 1 mapping data (survey and interviews) were being gathered. Approximately 20 providers were on this list, and in-depth discussions (including presenting to steering groups) in 16 providers ensued; one declined to take part, one was not suitable as Rounds rotated in four sites, and we decided that one was not suitable for a variety of reasons. Rounds were not sampled as a result of phase 2 survey responses, as survey and in-depth field work were often concurrent.

Following a pilot survey, we conducted a two-wave survey with 833 Rounds attenders at baseline (follow-up, n = 484) and 2680 Rounds non-attenders at baseline (follow-up, n = 578), to provide within-case controls. To maximise new attenders, seven sites were selected in which Rounds began during the study (see Chapter 5). Surveys comprised eight validated measures and additional demographic and Rounds-specific information, with a total of 47 items (see Report Supplementary Material 1 for details of the survey items). These items were selected to measure hypothesised mechanisms by which Rounds might be expected to work (see Appendix 1). Surveys were longitudinal and were administered before Rounds attendance (for attenders) and after 8 months (see Appendix 2 for the baseline and follow-up surveys). They were designed to evaluate whether or not regular attendance at Rounds has an impact on health-care staff well-being, social support for staff and behavioural change towards patients and colleagues, compared with staff who do not attend Rounds. The detailed methods and findings of the survey are reported in Chapter 5.

Realist evaluation methods were used in nine case study sites. 4–6,8 These sites were identified, using purposive sampling, to allow more in-depth work to be undertaken through interviews with Rounds attenders, panellists, facilitators, clinical leads, steering group members, board members and non-attenders, and non-participant observation of Rounds, steering group meetings and panel preparation. The case study sites were sampled to provide maximum variation of information-rich cases9,10 that included aspects of Rounds implementation theorised to have an important effect on implementation and Rounds impact (size of institution and percentage of total staff who attend; established and new Rounds providers11,12 and early and late adopters),13 and also a range of providers (see Table 2). Data from case study sites were collected to examine staff experiences of attending, presenting and facilitating Rounds and how Rounds are conceptualised and implemented, and the mechanisms by which well-being and social support might be influenced (or not). This included, for example, reasons for variance in attendance and attendees’ experiences, any influence on team hierarchy/teamwork and on coping with stress, and any reported behaviour change towards patients and colleagues, including wider ‘ripple’ effects felt in day-to-day practice. It had been our intention (as per protocol) to shadow staff in practice to observe ‘ripple’ effects, and we developed observation protocols to observe staff with patients with support from our patient and public involvement (PPI) group members. However, practically, it was very difficult to identify specific ‘ripple’ effects and follow staff in practice at the right times to observe these effects. We therefore omitted this aspect of data collection and informed the National Institute for Health Research of this change to the protocol. ‘Ripple’ effects were gathered through reporting in interviews.

Case study interviewees were identified through purposive and snowball sampling and then invited to take part. Informed written consent was taken and participants were given a unique identification (ID) number to ensure anonymity and confidentiality. The selection of panel preparation, steering groups and Rounds for observation was negotiated with the facilitator/lead site contact with the steering group and with individuals involved (panellists in panel preparation). In practice, researchers tried to observe every Round during their fieldwork period in each case study (5–6 months) and as many steering groups and panel preparation meetings as possible. Consent and confidentiality procedures were more challenging in Rounds. However, every effort was made to inform potential attenders about the presence of the researchers before the Round took place (e.g. on posters and in e-mails), thus giving attenders sufficient time to make a decision about attendance based on their knowledge of our presence. On arrival, attenders were asked to tick a box on a modified sign-in sheet, saying that they were happy for the King’s College London research team to observe the Round. As there was a possibility that attenders would not be aware of our presence prior to the Round, at the start of each Round either the researchers or the facilitators announced that researchers were present and were taking field notes, and explained that any participant could approach the researcher (who was identified to attenders) and ask for any information they may have provided during the Round to be withdrawn and not used in the research. We also undertook two focus group interviews in November 2016 with Rounds experts (mentors from within and outside our case study sites) to test our realist findings. Further details of the methods and findings from the in-depth qualitative case studies are reported in Chapters 6–8.

Mixed-methods analysis

Following the completion of all data analyses, we carefully examined the data from our separate phases/methods;14 for example, three members of the team (JM, CT and JD) interrogated our phase 2 survey data for the six case studies for which we also had qualitative data, and vice versa, and cross-referenced these in our findings where applicable. We reviewed the survey data by case study site and examined the descriptive statistics. Although the small numbers of regular attenders in each case study site prevented us from analysing these data any further, we have explored our divergent and similar results (see Table 28) and present the limitations of each method in Chapter 9. Our phase 1 mapping interviews were also analysed to inform our realist questions in phase 2.

Defining Rounds and reviewing their evidence base: methods

Searches for relevant material were made using (1) the databases PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE and EMBASE, giving comprehensive coverage of medical, psychological, nursing and social sciences literature (see Appendix 3); (2) contact with experts/Rounds leaders; and (3) internet searches. Searches were from inception to 2015; all searches were conducted between 14 October 2014 and 5 February 2015, except empirical studies evaluating Rounds, which we continued to search for over the duration of the project, resulting in two further papers included for this component.

For the composite definition of Rounds, we included all literature (including non-empirical literature, e.g. letters and editorials), providing that it included a definition of Rounds. Literature contributing to the evidence base for Rounds had to apply explicit research methodology.

Results

A total of 41 documents/sources were included in the review of definitions for Rounds (see Appendix 4 for the included references). The majority (n = 28) were non-empirical publications (e.g. commentaries, descriptive reports of a single Round, service evaluations of implementation). Thirteen research evaluations were identified (11 via the electronic/internet/expert searches, and two subsequent to this as published in 2016);18,19 however, for three of these20–22 only conference abstracts were available, and thus 10 publications were included in the review of evidence base for Rounds.

Methods

Results

A total of 11 alternative interventions were identified (Table 3). Electronic searches yielded a total of 1725 papers, of which 146 were included (ranging between 1 and 64 across interventions) (see Appendix 5 for a list of the included references). Of these, 74 were quantitative (randomised controlled trial, observational, quasi-experimental), 41 were qualitative (mixed designs, interviews, focus groups), 22 were mixed methods and nine were secondary studies (literature reviews). The literature was international, with the majority of studies from the USA and the UK; other countries represented included Canada, Australia, Finland, Norway, Sweden, Croatia, Spain, Italy, Israel and South Africa. There was a distinct lack of studies from Asia, although that may have been a result of the requirement that studies had to be in the English language.

A summary of the evidence base for each intervention is provided in Report Supplementary Material 3. For most interventions the evidence was sparse. Populations for many of the interventions lacked diversity across health professions and settings, with many mostly nursing-focused. The aims of studies varied widely, with a few aimed at assessing efficacy/effectiveness, but most were small-scale exploratory descriptive studies. The content/format of interventions (fidelity) was, in most cases, widely heterogeneous (and/or lacked detail), and, consequently, a synthesis of findings is problematic. Most of the quantitative evaluations across all interventions relied on weak study designs (e.g. they were cross-sectional studies or post-intervention evaluations, or were lacking control comparisons), used non-probability sampling and had small samples likely to be underpowered, and used non-validated outcome measures. Many qualitative studies also lacked rigour (e.g. limited reporting of member checking, deviant cases, reflexivity or evidence of data saturation).

Most interventions had been evaluated in relation to impact on all three layers of outcomes (self, others and organisation). Evidence for resilience training, mindfulness-based stress reduction and reflective practice groups lacked inclusion of organisational outcomes.

The findings suggest that all of the interventions had evidence of positive benefits to self (e.g. raised self-awareness, resilience, job satisfaction, empowerment, or overall well-being), and most provided some evidence of positive benefits to ‘others’ (albeit that interpretation is constrained by the methodological limitations highlighted above). For patients, this included a fostering of better relationships, communication with and/or attitudes towards patients; and improved patient-centredness, knowledge of patients’ suffering and empathy. For colleagues, this included associations with better teamwork, peer support and knowledge/understanding of colleagues.

At organisational level, there was evidence from some interventions of association with improved practice, for example reductions in unnecessary prescriptions, an increased uptake of psychosocial support (Balint groups), a reduction in task and co-ordination errors, and an increased uptake of post-fall huddles (after-action reviews). Two interventions provided evidence of a positive impact on the workforce, including providing opportunities for mentoring and advice (action learning sets) and improved staff retention (clinical supervision).

Exploration of theories about how Rounds may work (e.g. the context, mechanisms and outcomes related to Rounds)

This section aims to answer aim 5 above: to explore the theoretical literature on reflection, group work, disclosure and safe environment. In theorising about how Rounds might work, we needed to try to unpack the ‘black box’ of what happens in the monthly 1 hour of Rounds. To do this we drew on realist terminology, which uses the term ‘mechanisms’ to describe how interventions work, ‘context’ to describe the factors that trigger (or not) the mechanisms and ‘outcomes’ to describe the resulting effects. This initial theorising informed the development of our survey (see Chapter 5) and initial programme theory and interpretation of our study findings (see Chapter 8) (see Appendix 6 for a fuller review).

Methods

Theoretical literature was obtained using multiple strategies, including conducting searches on the internet and using databases such as Google Scholar; using key textbooks;35–38 consulting with our advisory and steering group members; and hand-searching references of key literature. Our approach to inclusion was broad at the outset – we did not restrict to theories that had a health-professional focus – but was focused by our understanding at that time about how Rounds worked and the key components of Rounds (e.g. from our composite definition reported earlier). For example, we initially explored all theories that had ‘reflection’ as a key component, but found that many early theories separated learning and emotion, and as emotion is central to Rounds we instead searched for theories of reflection that included emotion as a key element. We searched for theories describing reflection, group work, disclosure and/or safe environments either as outcomes (enabling us to examine mechanisms/antecedents to them) or as processes/mechanisms in themselves, leading to other outcomes. Theories were examined and included based on (1) their relevance to Rounds (e.g. group setting and emotion central to reflection) and (2) their relationship to context, mechanisms and outcomes based on our developing programme theory.

The initial development of Rounds in Boston, MA, USA, and underlying principles

Two members of the research team (ER and ML) visited the SCCH in Boston, MA, USA (8–12 June 2015). The purpose of the trip was to help develop our initial realist evaluation programme theory and identify the underpinning programme logic behind how Rounds are intended to work (see Box 3). This was based on information from those involved in developing and running Rounds, including the ‘programme architects’, Kenneth Schwartz’s family members, facilitators and members of the SCCH, and others currently running Rounds in the USA. We conducted two group interviews and three individual interviews, and observed two Rounds and one debriefing meeting between facilitators and a regional advisor from the SCCH.

Overall design

A mixed-methods approach comprising:

1. the collation and analysis of secondary data to map and profile Rounds providers

2. an online cross-sectional survey and telephone interviews completed by the clinical lead or facilitator in Rounds providers.

Sampling frames and samples

In our study protocol we estimated that there would be 40 Rounds providers by the start date of the evaluation (see Chapter 2). By September 2014, when the mapping phase began, there were 81 Rounds providers, and by the end of 2016 there were 154 providers. Given the challenge of evaluating a ‘live’ intervention (with Rounds adoption spreading rapidly during the life of the evaluation) and to provide as many current data as possible, the sampling frames differed for primary and secondary data sources.

The sampling frame for primary data collection (survey and interviews) was all providers in England that were running Rounds (defined as having been sent a contract by PoCF) at 1 September 2014 (evaluation start date) (n = 77). For secondary data, the sampling frame comprised all Rounds providers in England at 15 July 2015 (n = 115; see also Robert et al. 1). Providers in Scotland and Wales (n = 8) were excluded as (1) contracts were with health boards rather than individual providers and (2) comparable secondary data were unavailable. Provider details were obtained from the PoCF, as a licence was required from PoCF before Rounds were implemented, and so this was a reliable data source.

Data collection access

The PoCF requested permission from providers to share their details with the research team, giving 2 weeks to opt out: no provider refused permission. Local R&D approval was required for 66 of the 77 providers before invitations to participants could be sent. This was received from only 53 of the 66 that required approval (Figure 3). The clinical lead or facilitator for each provider that we had permission to contact was e-mailed the study information and invited to participate in the survey and interview.

FIGURE 3.

Recruitment and data completion for survey and interviews.

Surveys were received from 42 providers, although one was ineligible as it had not started running Rounds. Interviews were conducted with 48 individuals from 45 providers (three were interviews involving two participants together). Of the eligible providers (n = 76), the survey response rate was 41 out of 76 (54%) and for interviews the rate was 45 out of 76 (59%; see Figure 3). Among the providers that granted local governance approval (or did not require this), response rates were 41 out of 64 (64%) for the survey and 45 out of 64 (70%) for interviews. All sites were given pseudonyms to protect their anonymity. For site IDs we have used pseudonyms (rivers for mapping sites and trees for case study sites) (see Appendix 8 for provider profiles).

Most providers completed both the survey and the interview (n = 39; the same participant completed both in 35 providers). Six providers participated in the interview only, and three completed the survey only.

Data collection

Pilot testing

The survey and interview schedule were piloted with project advisory and steering group members, and three ‘critical friends’ who facilitated or led Rounds. Minor changes to the survey resulted (e.g. ensuring that staff groups also reflected non-NHS categories). Following discussion of interview questions in the first 3 months of data collection, a question asking how respondents felt Rounds ‘worked’ was removed (as interviewees found this difficult to understand and answer). This was replaced with ‘Do you think Rounds have an impact on staff? If so in what way(s)’ (respondents were encouraged to consider short-, medium- and longer-term impacts).

Data analysis

How many and what types of organisations were running Rounds?

At 15 July 2015, 115 organisations in England had ‘adopted’ Rounds (Table 6). Over half (n = 71, 62%) were based in the south of England, with over one-quarter of all providers located in London (28%). Figure 4 shows the location of current Rounds providers (up to the end of 2016) (n = 154).

FIGURE 4.

Location of Schwartz Rounds sites in England (n = 154) up to the end of 2016. © OpenStreetMap contributors. These data are made available under the Open Database Licence http://opendatacommons.org/licenses/odbl/1.0/. Any rights in individual contents of the database are licensed under the Database Contents License: http://opendatacommons.org/licenses/dbcl/1.0/.

© OpenStreetMap contributors. These data are made available under the Open Database Licence http://opendatacommons.org/licenses/odbl/1.0/. Any rights in individual contents of the database are licensed under the Database Contents License: http://opendatacommons.org/licenses/dbcl/1.0/

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.

Why were Rounds implemented?

A combination of secondary data, survey and interview data was used to explore this.

How are Rounds being implemented?

Measuring/evaluating the impact of Rounds

The PoCF require organisations to use a bespoke evaluation form, and to provide a review of findings after the first nine Rounds. Most sites (n = 35) reported collating summaries of Rounds, and having systems for collating and summarising feedback. Three-quarters of sites reported that they analysed sign-in sheets, and all analysed the evaluation forms. These analyses were most commonly used to report to the steering committee (n = 38) and to the board (n = 27). Some used the analyses for promotional material (n = 9) or quality accounts (n = 7).

Determining the impact of Rounds was a topic that elicited a variety of responses in interviews. Some interviewees said that they found the questions about impact difficult, were hesitant, or prefaced their answers with comments about the lack of ‘hard evidence’ for the effects of Rounds or the difficulties of measurement and attributing causality. Most respondents referred to overwhelmingly positive attender feedback on Rounds, but clearly felt that they needed to give circumspect answers in the absence of ‘direct evidence’ of impact:

It’s very hard to give you tangible [. . .] hard quantitative type of evidence, but what is clear is that when staff attend, the evaluations after the event are incredibly positive.

Severn-395-Facilitator

Respondents were often reluctant to answer questions about the impacts of Rounds, such as on staff well-being or delivery of patient care, saying that it was too early to tell, or that they were not in a position to observe (or measure) effects or make judgements about them. In relation to the impact on themselves, respondents who had been panellists spoke about this [e.g. ‘helped me process some, perhaps difficult, emotions that I hadn’t been able to do before’ (Horse-chestnut-194-Clinical Lead)]. Others highlighted the benefits of taking the role of the clinical lead or facilitator, giving examples of Rounds influencing their behaviour towards patients or colleagues:

It certainly makes me a bit more aware of colleagues and pressures and things like that, so yes, I’d have to say yes, a slightly different approach. Probably don’t send off as many angry e-mails as I used to.

Tiber-151-Clinical-Lead

Although interviewers asked respondents to consider negative impacts as well, respondents mostly gave examples of positive effects and few discussed the possibility of harm. One exception was a facilitator who spoke of an audience member who had been adversely affected by a Round:

So we’ve had an allied health professional who wasn’t able to sleep the night after the Round, it churned things up for them, resonated with them, some case that they hadn’t resolved in their mind.

Chess-388-Facilitator

Challenges in running/sustaining Rounds

The main challenges to running and/or sustaining Rounds were subsumed under two themes: (1) issues to do with attendance and in particular widening accessibility, and (2) issues to do with the workload and resources required to run Rounds (Table 10; see also Appendix 12 and Chapter 7).

What were the resource implications of running Rounds in organisations?

Design and setting

A two-wave survey of new Rounds attenders and non-attenders was conducted in 10 case study sites from 29 May 2015 to 8 October 2016. New attenders (i.e. those who had not attended a Round previously) were chosen for the intervention group so that it would be possible to detect the effect of starting to attend Rounds.

The 10 case study sites were identified, using purposive sampling, in order to maximise the variation of organisations in terms of size, location and type of provider. Four of the sites had been running Rounds for a number of years; at the other six, Rounds began during the study, meaning that we could recruit participants at their first ever Round (and most attenders would be attending their first Round). Six of the sites (including two ‘new’ Rounds providers) were also main case study sites (see Table 2). Originally we planned that the same 10 sites would fulfil both purposes, but following the pilot study it was determined that this may not yield enough new attenders, and therefore four established Rounds sites were replaced by four new Rounds sites.

Seven of the sites were acute trusts. One site ran Rounds jointly between an acute trust and a nearby mental health trust. One site was a mental health trust alone, and the final site was an independent (non-NHS) hospice. Negotiation for access to each was sensitive throughout to issues of data anonymity, confidentiality, informed consent and burden placed on staff.

The sample size for the survey was based on a power calculation involving the primary outcome, work engagement (see Appendix 13 for details). 78 An increase of 0.33 in work engagement is associated with a 0.5% drop in staff absence (per staff member, this translates to more than 1 day fewer absences annually); we considered this an important difference. Based on the variance in work engagement from the national NHS staff survey, the total sample size required to detect this effect, with 80% power and allowing for clustering, was 228 (114 in each group). Allowing for a 50% response rate, a dropout between baseline and follow-up of 40–50%, and assuming that 50% of new attenders would become regular attenders (see definition below), a sample of 800 new attenders was needed. Following the pilot study, it was acknowledged that an average of 80–100 attenders in new Rounds sites, and 30–50 in established sites, could be achieved by recruiting up to four Rounds in each site, yielding a probable total sample of between 650 and 850 attenders.

For non-attenders, we assumed that the initial response rate would be lower, and the dropout rate between baseline and follow-up would be higher (as some respondents may become Rounds attenders). In addition, it was not possible to know in advance who had attended Rounds previously. Therefore, an initial random sample of 250 staff per site was chosen at eight sites. At the hospice, however, the size of the whole organisation was smaller than this, and at the joint acute/mental health site a sample of 250 staff across each organisation was used, meaning that the total initial sample size for the non-attender arm was 2680.

Recruitment and administration

Inclusion and exclusion criteria for participation were as follows. Note that categorisation into different groups could not happen until after the follow-up survey.

• Inclusion criteria:

  • (all groups) staff who have the opportunity to attend Rounds, and have not attended Rounds before the baseline survey

  • (regular attenders) staff who attended ≥ 50% of available Rounds between the two surveys

  • (irregular attenders) staff who attended at least one Round but < 50% of available Rounds between the two surveys

  • (non-attenders) staff who had not attended a Round previously, and did not attend one during the study period.

• Exclusion criteria:

  • people not employed by the provider

  • staff who had attended Rounds previously, including with a previous employer.

Recruitment and survey administration differed for attender and non-attender arms. In both cases, potential participants were first asked whether or not they had previously attended any Rounds: if they had, their participation ceased. See Appendix 13 for details of recruitment.

Measures

The 47-item questionnaire included the following measures, selected based on our literature review and initial theorising regarding how Rounds were expected to work (see Chapter 3). Unless stated, questions were asked in both the baseline and follow-up surveys in the attender and non-attender arms (see Report Supplementary Material 1 for full details of the measures and their reliability and validity):

• work engagement

• psychological well-being 12-item General Health Questionnaire (GHQ-12)

• self-reflection

• empathy

• communication with patients

• compassion

• peer support

• organisational climate for support

• absenteeism

• age, gender, occupational group, tenure with the organisation, grade, working hours

• extent of contact with patients

• (follow-up survey only) number of Rounds attended in the previous 8 months

• (attenders only) reasons for attending Rounds; whether or not they had attended in their own time; whether or not they had attended with immediate colleagues; whether or not they had ever presented at a Round; whether or not they contributed to Round discussions; and perceived usefulness of Rounds

• (non-attenders only) reasons for not attending Rounds.

Analysis strategy

The primary hypothesis was that there was a greater improvement in work engagement for regular Rounds attenders than for non-attenders. This was tested via a multilevel (to adjust for clustering within sites) analysis of covariance (ANCOVA), with work engagement at follow-up as the dependent variable, and work engagement at baseline as a covariate (this is mathematically equivalent to examining the change in work engagement with the baseline value as a covariate, but reduces non-essential covariance and other problems associated with difference scores). 79 The analysis also included occupational group, grade, gender, age, length of service, working hours and extent of contact with patients as covariates.

The secondary outcomes were psychological well-being (Likert and ‘caseness’), self-reflection, empathy, communication with patients, compassion, peer support, organisational climate for support, and absenteeism. Most were examined using the same model as for the primary outcome (with checks to ensure that key assumptions of the model were not violated). The ‘caseness’ score of the GHQ-12 was analysed with a multilevel logistic regression model, and absenteeism with a multilevel negative binomial model.

Three further analyses were completed:

1. We used alternative definitions of regular attenders. It became clear during the fieldwork that using a strict 50% definition might mean that an irregular attender at one site had actually attended more Rounds than a regular attender at a different site, owing to imbalances in the frequency of Rounds at different sites. We adhered to this definition in our main analysis, but also tested alternative definitions of regular attenders in which two, three or four Rounds, respectively, were attended to meet the definition.

2. We tested the difference between anyone who had attended Rounds and those who had not, and used the number of Rounds attended as a numerical predictor of outcomes (with both linear and quadratic models): this is a direct test of whether or not the dose of Rounds has an association with changes observed.

3. To account for imperfections in the design and data collection, we also conducted three sensitivity analyses and examined potential moderators of the effects.

Descriptive statistics: sample

Including respondents from our pilot study, there were 1140 responses at baseline and 500 at follow-up, excluding 18 blank responses (15 in the main study and three in the pilot study) (Table 13).

There were 500 responses from participants at both time points: 207 of these were originally recruited as attenders, and 293 as non-attenders. However, 54 of the non-attender group subsequently attended at least one Round. A further six did not indicate (on the follow-up survey) whether or not they had attended any. Five of the attender group also did not indicate (on the follow-up survey) how many Rounds they had attended. Therefore, these 11 respondents could not be categorised. The total number in the final sample (293 + 207 = 500; 468 from the main study) (see Table 13) is larger than the 489 classified into the three groups (see below) because of the 11 who could not be categorised.

The numbers in each group, as defined in the protocol, were as follows:

• regular attenders – 51

• irregular attenders – 205

• non-attenders – 233.

Of the combined attender groups, 140 had attended at least two Rounds, 77 had attended at least three Rounds and 40 had attended at least four Rounds. The number of regular attenders was smaller than anticipated. This was because of a lower conversion rate to regular attendance than had been anticipated in the study design.

A breakdown of attendance, other background characteristics and survey completion details is given in Appendix 15. In many aspects, the profile of attenders and non-attenders is fairly similar. However, there is a bias towards clinical staff (particularly AHPs/scientific and technical staff) among attenders, and also towards more senior staff (particularly bands 7 and 8a). These differences are controlled for by including background variables (site of study, occupational group, grade, gender, age, length of service, working hours and extent of contact with patients) as covariates. Unless otherwise stated, all subsequent analysis includes these covariates and accounts for clustering by site using multilevel analysis.

Comparison of regular attenders and non-attenders on outcomes (primary method)

Table 14 shows the raw (unadjusted) means and standard deviations for each survey measure at baseline and follow-up in each of the groups. Of note is the high levels of poor staff well-being in our sample, as measured by the GHQ-12 caseness, suggesting that, at baseline, between one-quarter and one-third of the staff in our sample had sufficiently poor psychological health that they would benefit from professional intervention. This was a slightly higher than the 27% prevalence reported in a large previous study of NHS staff. 80

There are some baseline differences between the groups, in particular between attenders and non-attenders. To examine the extent to which these reflect genuine systematic differences, as opposed to random fluctuations or differences in the background profile of the groups, we ran multilevel ANCOVAs (or equivalent multilevel generalised linear models) in which baseline values were predicted by group membership, controlling for background variables.

Most of the differences were not significant, with one important exception. Engagement was significantly lower among non-attenders than among regular attenders [adjusted difference 0.33; 95% confidence interval (CI) 0.05 to 0.62; p = 0.022]. This has implications for how subsequent results are interpreted, not least because engagement was specified as the primary outcome measure. It may be that findings could be affected by the baseline imbalance, which would justify using baseline measures as covariates in the main analysis.

There appear to be differences between the groups for self-reflection [F(2,320.8) = 4.886; p = 0.008]; however, post hoc tests of the specific group differences do not yield significant results. In particular, the difference between regular attenders and non-attenders is not quite significant (difference 0.36; 95% CI –0.02 to 0.75; p = 0.064). Nevertheless, this difference could have an impact on findings. Likewise for peer support, the overall group difference was just significant [F(2,324.2) = 3.048; p = 0.049], but the pairwise group differences were not, with the difference between regular attenders and non-attenders being 0.33 (95% CI –0.04 to 0.70; p = 0.076). For no other variables did the differences come close to significance. Correlations between survey variables are shown in Appendix 16. One aspect of the correlation between all the survey scores and the number of Rounds attended (see Appendix 16, Table 44) is that there do not appear to be any substantial correlations between psychological well-being and the expected intermediate mechanisms of self-reflection, empathy, communication with patients and compassion, suggesting that levels of psychological well-being are not related to these mechanisms in the way that had been anticipated. Table 15 shows the change from baseline to follow-up surveys in these scores for the two principal study groups, together with the adjusted difference between these groups.

It can be seen that most of the differences are small and non-significant. In particular, there is no effect found with the primary outcome (engagement).

The only significant effect is on the caseness score of GHQ-12: the binary categorisation of whether or not the respondent is sufficiently stressed as to warrant intervention. This decreased significantly more in the regular attenders than in the non-attenders group (a 13% decrease, compared with a 3% decrease in unadjusted scores). The odds ratio for this effect was 0.28 (95% CI 0.08 to 0.98); that is, the odds of being identified a case by the GHQ-12 were approximately 72% lower for regular attenders than for non-attenders.

The full results from the models reported in this section are available in Appendix 16.

Comparison of regular attenders and non-attenders on outcomes (alternative definitions)

As reported earlier, owing to inconsistency in the number of available Rounds at different sites, we also tested different thresholds for ‘regular’ attendance. We tried this with the requirement that either two, three or four Rounds should have been attended. In addition, we examined effects of any attendance.

In most cases the same conclusion was reached: there was no overall difference between regular attenders and non-attenders for most of the variables. Table 16 shows the regression coefficients for the primary outcome (engagement) and odds ratios for GHQ-12 (caseness) that had the significant result in the main test.

There was no difference between the groups in engagement regardless of the definition. For GHQ-12 caseness, measuring psychological well-being, there is a significant effect for attendance at two or more Rounds. The odds ratio of 0.40 suggests that the odds of being severely stressed are nearly two and a half times smaller for people who attend (at least two) Rounds than for people who do not attend, controlling for their psychological well-being before attendance. The effects for attending at least three or four Rounds are not statistically significant, even though the odds ratios are of a similar magnitude (for at least three Rounds) or greater (at least four Rounds). This is probably because of the smaller numbers attending at least three Rounds (n = 77) or at least four Rounds (n = 40). Even if a single Round is attended, there appears to be a significant effect: the odds of caseness are reduced by 43% compared with non-attenders.

We also examined whether or not there was any evidence that attending a greater number of Rounds was associated with a greater degree of change in outcomes. Full details are given in Appendix 16, but the analysis backed up the previous results: there was a significant effect for psychological well-being only (in both caseness and Likert form this time), with more Rounds attended associated with better well-being at follow-up.

Sensitivity analyses

As with most studies, the administration of the survey and integrity of the sample were not perfect, with three areas of concern:

1. incomplete data (< 10% on most variables, although slightly higher for some demographic variables; see Appendix 15)

2. some areas of the survey applying only to staff who had regular contact with patients

3. changes in respondents’ work between baseline and follow-up surveys.

As such, the principal analyses [those reported in Comparison of regular attenders and non-attenders on outcomes (primary method)] were repeated under different conditions.

• A full information maximum likelihood analysis was conducted (using Mplus; Muthén & Muthén, Los Angeles, CA, USA81) with all data to examine whether or not the results were affected by incomplete data.

• Analyses were repeated with only those respondents indicating that they had regular contact with patients.

• Analyses were repeated excluding any respondents who indicated in their follow-up questionnaire that their role had changed in any significant way, or (in a separate set of analyses) that they had moved organisation since the baseline survey.

In all cases, the conclusions reached were the same as those from the main analyses (i.e. that there was a significant effect on the GHQ-12 caseness score of psychological well-being, but not on the other outcomes). Therefore, we can conclude that the findings we reach (including the lack of significant results in most cases) are unlikely to be because of these areas of concern.

Moderator analysis

We examined a variety of other factors that might have had an impact on any effects of attendance at Rounds. The full results are in Appendix 16, but there were only three significant findings, which did not fit with prior expectations and are not easily explainable, and therefore are likely to have been type I errors.

Usefulness of Rounds

Respondents who had attended Rounds (whether or not regularly) were asked (in the follow-up survey) how useful they considered Rounds to be, on a scale from 1 (not at all useful) to 5 (very useful) (Table 17).

The majority of respondents in both groups found them more useful than not, but a higher proportion of regular attenders than irregular attenders described them as very useful, with a more even balance between somewhat useful and very useful. Among the irregular attenders, 5% found them not to be useful, and 16% felt neutral about their usefulness. This may give some clue as to why these respondents did not become regular attenders, although as the following section will show, there are other reasons.

We examined whether or not the perceived usefulness of Rounds (among attenders only) was associated with changes in the outcome variables. These models were based on the same types as previous models [multilevel ANCOVA for most outcomes, but multilevel logistic regression for GHQ-12 (caseness) and multilevel negative binomial regression for absence], controlling for the same covariates as the previous analysis.

Most models did not produce significant results, with no reason to suggest that the more useful an attender found Rounds, the more likely outcomes were to improve. However, the exception again was psychological well-being. For both versions of this outcome, relationships were found. In particular:

• For the caseness version of GHQ-12, there was an odds ratio of 0.56 (95% CI 0.36 to 0.86; p = 0.009); that is, for each extra degree of usefulness perceived (e.g. moving from neutral to somewhat useful), the odds of being classed as a case would diminish by about 44%.

• For the Likert version of GHQ-12, there was a regression coefficient of –0.11 (95% CI –0.16 to –0.05; p < 0.001); that is, for each extra degree of usefulness perceived (e.g. moving from neutral to somewhat useful), the GHQ-12 Likert score would move down on average by 0.11 points.

The two versions here give somewhat differing estimates of the importance of the effect; however, the conclusion from both is similar. The more useful attenders perceive Rounds to be, the higher their levels of psychological well-being after 8 months (when compared with their levels at baseline).

Other survey results

The survey included a variety of questions about perceptions of the Rounds and availability to attend (for attenders), or reasons for not attending (for non-attenders). These are summarised in the following tables.

Table 18 shows the reasons that regular and irregular attenders started attending Rounds. Being prompted to attend by managers or colleagues was an important reason for attending; however, interest in a topic was also regularly cited, and publicity had an effect.

Under the ‘other’ option, respondents were invited to write why they had begun to attend. Most responses here were variations on the above options, including combinations of them, but others included ‘I’m interested in finding out if the Trust will be improving how staff deal with their emotions regarding stress’; ‘It was offered at work and I had emotional admissions at work this last few weeks so came for support and to see if it helps’; ‘I think it has been a time of many changes and an opportunity to stop, reflect and take stock is important’; ‘I am very interested in the reflective process and encouraging staff to discuss and explore their feelings’; and ‘To see if it would add anything to what we already do in our team’. Clearly, the role of stress and emotions at work was important for some people, and also some people saw Rounds as an opportunity to take time out, reflect, and determine whether or not things could be improved.

Thirty per cent of regular attenders and 27% of irregular attenders said that they always managed to attend Rounds when they wanted to. Barriers preventing attendance are shown in Table 19 (respondents could choose as many options as they wanted).

The main reasons for not attending Rounds more regularly were practical: most of all, the pressure of time, and either not physically being able to get to Rounds (because of schedules or locations) or other things being seen as priorities. The role of seniority and autonomy in being able to attend was clear from a couple of the comments (e.g. ‘I had time, when I was on an office day. These are unrealistic for clinical floor staff like nurses who have a job to do on the shop floor’). When asked why Rounds were useful or not, one respondent said:

For most of the floor caregivers they have no idea of the existence of these Rounds let alone what happens at them. They seem to cater for middle managers, and doctors at a certain grade who can take an hour out of their day to go and attend. Mostly they are scheduled at a lunchtime. In a 40-bed ICU [intensive care unit] or A&E [accident and emergency] it seems a little unrealistic to send staff as each nurse always requires another nurse to relieve her to go anywhere.

Other questions about attending Rounds are summarised in Table 20.

Clearly, attending Rounds in one’s own time was crucial for attendance, with nearly half of all respondents having done this at least some of the time. Attendance with colleagues was another important factor, with just 10% of regular attenders not having attended with immediate colleagues. Regular attenders appeared more likely to contribute to discussions (although this may be because more Rounds attendance increases opportunities for participation in discussions).

Non-attenders were asked why they had never attended Rounds (Table 21) (respondents could select multiple options).

Some of the key reasons for non-attendance were respondents being unaware of what Rounds were, not thinking that they were invited (publicity issues) or not thinking that Rounds were relevant to their role; however, other key reasons fitted with the attenders’ barriers regarding time and other priorities.

Attendees’ experiences

In this section, we describe the enablers of and barriers to attendance at Rounds, factors influencing whether or not audience members speak, staff perceptions of Rounds, and Round attendance outcomes.

Panellists’ experiences

The panellists we interviewed came from diverse backgrounds, disciplines and roles. Most had attended Rounds as an audience member, and a few were, or had been, facilitators. We interviewed 39 panellists to gain their perspectives.

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.

Experiences of panel preparation

Panel preparation played a significant role in shaping stories, giving panellists the confidence to tell their story publicly, and defused some of the raw emotion:

Well I burst into tears, I cried through the whole thing. [I felt] so much better that [I’d] done that. Yeah so we just had a quick run-through about how what we were going to talk about affected us and the wider kind of organisation.

Sycamore-09-Panellist

For many, this preparation helped panellists feel ‘safe’ to tell their story and provided emotional support, some ‘closure’, and catharsis:

Yeah. I think – [in the panel preparation] the planning, I think we certainly got – I think we were using the word ‘closure’ quite a lot, and I think that was really helpful.

Cedar-27-Panellist

It also helped panellists decide on the content (critical moments or an aspect of an experience), style and structure, and to think through the implications of what they chose to reveal, for both them and the audience, so that whatever they decided to share was done so with informed consent. Panellists varied considerably in the amount and type of preparation that they needed, and received. The panellist quoted below (who had presented several times before) explained how he felt that the preparation was more for the facilitator’s benefit:

It was more of a reality check for them because they [facilitator] didn’t really know what we would be coming up with [. . .] they didn’t necessarily know whether I would be able to present it in a way that was interesting to people coming to a Schwartz Round [. . .]. So it was much more of them listening to what we were going to talk about. Maybe one or two queries about ensuring that we were going to be able to discuss how we felt about it at the time.

Sycamore-12-Panellist

Panel preparation was not available to all, and when it was available it varied in frequency and quality. Some who received no or limited panel preparation felt that they had ‘survived’ the Round rather than fully engaged with it:

I did feel relieved that I survived it and I felt relieved that [my story] hadn’t been in one direction and everybody else has been in the other.

Ash-04-Panellist

Pre-Round expectations

It was not unusual for panellists to present at a Round without having attended one, and some had preconceived ideas of what it might be like:

I almost thought it was going to be like a circle [. . .] and everyone shares experiences within that. It wasn’t like that [. . .] it felt very safe.

Mulberry-25-Panellist

Participants explained that they had been worried about the relevance of their story or that having people they knew in the audience would make them more nervous, or that they would feel intimidated by the seniority of other panellists:

Yeah I was a little bit nervous at first when I realised who else was on the panel. And it seemed to be that everybody there was quite a lot higher up than me. But I think it went quite well.

Ash-02-Panellist

Experience of presenting

Facilitators were described as supportive and their role in keeping Rounds safe was recognised. Some panellists felt anxious because they had performance nerves, or they were worried about the audience’s reaction to their story or about being emotional in the Round. However, once panellists had presented, their concerns were generally replaced with feelings of fulfilment, benefit and privilege. Most spoke positively about the experience:

It was really good yeah. I was really surprised at the amount of people that turned up [. . .] I think I probably hadn’t really thought about what it would be like to do it. So I mean it was good really, I hadn’t really known what to expect, but the experience was really good.

Trent-29-Panellist

Several judged the success of the experience by the level of discussion following their presentation, and whether or not their story was referred to. Most found the audience receptive and supportive.

Many panellists reported that they felt honoured by the realisation that they had held the audience’s attention:

Yeah, I felt listened to, I felt – and I was scanning the room as much as I could to see people’s faces and they were all focused and whoever was talking they was all focused on that one person [. . .] that’s quite an honour to be in that position to have people’s attention for that length of time.

Mulberry-01-Panellist

I think it went well [. . .] the feedback when people took part, that was really interesting. So I felt that people were engaged and that must be deemed as a sign of success really.

Ash-01-Panellist

A minority told how they had witnessed direct negativity from members of the audience, which left them feeling upset. Although many panellists embraced the emotions associated with Rounds, some found the experience emotionally exhausting. In a Round, after the panellists share their stories, the facilitators hand over to the audience, and there is often silence before the first person speaks, which can be uncomfortable:

After the panel had spoken, the audience I find go into this terrible silence, you can almost hear people thinking shall I say something, I’d really like to say but I’m not brave enough, but then once someone gives their opinion or gives their thought then other people start to put their hand up and speak.

Elderberry-04-Panellist

Others, however, learned to appreciate the silence. The interviewee quoted below explained how she interpreted the silence:

I think for me it was the silences [. . .] that’s what’s so powerful about Schwartz is that it’s, there’s that pause, it’s you’ve been and you’ve shared [. . .] And sitting there for me having shared that, that sacred space if you like, that gap wasn’t suddenly filled unnecessarily. It was like it was all this is, and then people did come and chip in, but that was really powerful that gap [. . .] And it really makes it feel really, really sacred and puts the dignity into what’s being said, or it did for me that day.

Elderberry-11-Panellist

Panellists reported a number of positive outcomes associated with their experience on the panel, including a greater sense of affiliation with the wider organisation and feelings of fulfilment, energy, inspiration, motivation, catharsis, closure and validation. Several felt that the experience had brought a new perspective to their story, prompting them to share previously unspoken feelings. Others described how the experience had increased their resilience and self-awareness and had altered their interactions with others, for example increased dialogue between colleagues, feelings of greater approachability and trust between coworkers, and more acceptance of others’ behaviour.

Facilitators’ and clinical leads’ experiences

Rounds are usually co-facilitated by facilitators and clinical leads. A facilitator often takes the lead role (especially in audience discussion, holding responsibility for the Round) and the clinical lead takes a supportive role (explaining the purpose of Rounds and establishing the ground rules). We interviewed 27 participants from the nine case study sites. Facilitator style is presented in Chapter 7.

Steering group members’ experiences

We interviewed 25 steering group members from the nine case study sites. An active steering group was reported as essential in supporting Rounds, for example in sourcing stories and panellists, debriefing and evaluating Rounds, advertising Rounds and booking venues. We noted the diversity of steering groups, in terms of how often they met, the types of contributions made by members, and the size of the core and extended steering groups (see Chapter 4 for more on steering groups).

Some facilitators valued the steering group presence with the Round audience, both as a source of observation (when considering ways to improve) and as an opportunity to role model (preferred audience behaviours) through their contribution to the discussion (see Chapter 7 for more on what makes a Schwartz-savvy audience): ‘I think it’s about having the steering group in the audience and alert and ready to pick things up and just giving support to the facilitators at the front’ (Cedar-05-Facilitator).

Some steering group members described how they had been part of the team that brought Rounds to their organisation, having led negotiations with senior stakeholders: ‘I was part of the original steering group that helped to get them [Rounds] going. My role involved helping to get a buy-in from the board’ (Mulberry-05-Steering-Group-Member).

Those whose involvement began once Rounds had been established described being invited to join the steering group as a representative for some (often under-represented) staff groups, with the intention of promoting attendance among such groups:

[The clinical lead] was keen that there would be a junior doctor representative because we’re quite an under-represented group in terms of the people who go to Schwartz Rounds at the moment [. . .] So I said that I would encourage my peers to go.

Willow-05-Steering-Group-Member

Steering group members described their contribution, most of which related to Rounds promotion: displaying posters, updating the staff intranet pages and telling people about Rounds. Some helped identify panellists and stories. Others saw their role as a reviewer, assessing the Round and making suggestions for change if necessary:

I think the role on the steering group is just to try and give honest feedback about the particular Round – about what could have been done differently. Not necessarily better, but just differently – whether a new idea or something worked or didn’t work.

Willow-06-Steering-Group-Member

We often heard from facilitators that the steering group had diminished in size, with enthusiasm and attendance dropping over time.

Stakeholder experiences

We explored how board members (e.g. executive and non-executive directors) viewed and contributed to Rounds.

Most spoke positively of Rounds, for example:

I think they’re [Rounds] a really important part of what we offer [. . .] the Schwartz Rounds brings people together from all walks of life, all jobs and it gives them permission to speak and it feels safe.

Elderberry-08-Stakeholder

In our case study interviews with facilitators, we detected an anxiety concerning the need to produce ‘results’ (i.e. that some measurable impact of Rounds was required to get continued support from stakeholders), but this was not reflected in stakeholders’ interviews.

Some board members had been panellists and had talked about their own emotional distress in the hope that others would benefit from their experience:

I spoke about my own personal experience of having suffered from depression [. . .] I just didn’t find it easy to talk about it, but I think it was fine. And I was really glad that I had done it [. . .] I had a feeling that there were people there who may have also suffered from depression or be suffering from depression and may have found it quite a hopeful story.

Cedar-24-Stakeholder

Despite being a regular attender, one board member explained her reluctance to contribute as a panellist or an audience member:

I mean my own philosophy is that I don’t really talk at that [Rounds] because I’m just wondering what, I don’t know, because of my position I’m not sure that it’s necessarily a great idea [. . .] not appropriate [. . .] I see myself very much as watching and listening rather than taking part.

Elderberry-20-Stakeholder

The opportunity to be an influential role model for junior staff was welcomed by one board member who, as a panellist, spoke about their (sometimes negative) feelings towards patients, in the hope that others would follow:

I believe you’ve got to lead by example really [. . .] [I spoke about] a patient from a personal point of view [and asked the audience] could you ever like this person? And they were all saying no. They were talking as human beings and I let them do that and I think that’s what Schwartz Rounds are about, they’re just, we are all human beings. So yes leading by example and let them know it’s OK to do it and if the boss is doing it then it’s OK for them.

Juniper-25-Stakeholder

Some described their involvement as that of a figurehead. Although board members might not always attend Rounds, a number kept informed through minutes and reports.

Stakeholders from new providers anticipated positive changes to employees’ experiences at work as a result of the introduction of Rounds:

I’d like to think in our snap surveys of staff that people will start to report that actually they feel that there’s a greater recognition of the demands for them in their work.

Mulberry-26-Stakeholder

It was predicted that such changes might be accompanied by improvements in organisational performance:

There will be evidence [of impact] I think there’ll be some hard outcomes and some soft outcomes [. . .] People feeling a bit of confidence and trust in the organisation which should then potentially lead to high levels of retention, because people feel as if all of their learning needs are being met. The soft outcomes, people will really feel safe and have that confidence and trust in the organisation.

Juniper-26-Stakeholder

Non-attenders’ experiences

We interviewed people who said that they had never been to a Round to find out why this was the case (see Chapter 5 for survey respondent reasons).

A few participants were well informed about what happens in Rounds and had deliberately decided to opt out:

I had the opportunity to attend, but when I realised it was as emotionally charged as it was I went, yeah, I’m not sure I’m really ready, to go there and be faced with that level of emotion [. . .] I thought it may be just a bit too much for me.

Elderberry-36-Non-Attender

The non-attender data suggested that many staff did not really understand what Rounds were. A few gave generic explanations, for example that it was an intervention intended to help staff deal with difficult issues. Others (from across all staff groups) felt that Rounds publicity did not always give enough information to make a decision about whether or not to attend, particularly in the new Rounds sites: ‘I read about Rounds quite a lot but I have no idea what they are or what they do or what they’re intended to do’ (Mulberry-29-Non-Attender). There were also other misunderstandings. For example, one non-attender’s response showed that they were unaware that Rounds were open to all:

I might ask the manager how can I go about inviting myself and take it from there, or I could speak to the person that sends out the e-mails, I’ll probably ask her as well how I could get myself invited, just as long as I could stay at the back and I could just listen as opposed to being somebody that has to talk.

Elderberry-36-Non-Attender

A few interviewees said that they had attended Rounds but went on to describe a different meeting, highlighting the misunderstanding that existed for some. Others did not feel that Rounds were for their staff group, suggesting that they were more for doctors than nurses, and that certain roles, such as non-clinical, did not warrant attendance.

Individual capabilities and characteristics of key actors

Rounds are usually run by a core group of key actors: one or more facilitators, a clinical lead, an administrator and steering group members. In this section, we focus on the roles of facilitators and clinical leads (see Chapters 4 and 6 for more on other roles, and Report Supplementary Material 5 for selected role guidance from PoCF). We identified differences between our case studies in the following:

• facilitators’ background, experience, skills, knowledge and training

• facilitators’ passion, understanding and belief in Rounds

• facilitator and clinical lead style.

Interpersonal relationships: behind-the-scenes support given by core team and steering group

The majority of Rounds attenders only see what happens during the 1 hour of a Round; however, the core team and steering group provide behind-the-scenes help to put on a Round, including using their networks to gather organisational intelligence.

Organisational setting

In this section, we compare across organisational settings in relation to:

• organisational factors

• time running Rounds

• audience characteristics

• Rounds’ characteristics.

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 ‘Schwartz savviness’

Over time, Rounds participants become ‘Schwartz-savvy’, by which we mean that they really understand the purpose of Rounds, know and follow the explicit and implicit rules of how to contribute appropriately and support each other in a non-judgemental way. In some sites, we observed that facilitators, clinical leads and steering group members in the audience role model appropriated contributions and support, sometimes intentionally and other times unintentionally. In one sense, having a ‘Schwartz-savvy audience’ is a sign that Rounds are becoming embedded within the organisation.

Some interviewees suggested that Rounds were a ‘slow-burn intervention’, that they took time to develop successfully and that there was an important longitudinal element to participation, which over time created a staff community intervention in organisations. Our data in longer-established Rounds sites suggest that, over time, if the Rounds have fidelity to the core Rounds components, this creates a ‘Schwartz-savvy audience’, which provides a further resource in terms of a support community that newly set-up Rounds organisations do not have. Two mentors discussed this in our theory testing focus group:

I think it’s what you call [a Schwartz-savvy audience] a massive resource for the facilitators because I think [. . .] when you start initially, you are on your own, a few of you taking a massive risk and being very publicly exposed. And if it becomes embedded, you start to not be on your own anymore. The Schwartz-savvy people carry it with you [. . .] And there are more of them and initially even the first year, possibly the second year [. . .]

. . . Yeah, it’s into the second year and I remember we did a really risky one I think on organisations and we got about 150 people and I thought this is going to be impossible to facilitate, we’ll never be able to do it, and then I realised that there was a community – what you’re calling the ‘Schwartz-savvy people’ – that held it with us. So they started speaking – most people wouldn’t speak in front of 150 people [. . .], and that’s why I think it’s a slow intervention because you have to create that organically over time.

Focus group-14.11.16

Panellist, audience and facilitator trust and confidence

Facilitators spoke of needing to gain confidence in their facilitation style (see Chapter 6) to take more calculated risks in Rounds when they felt that the organisation and audience was ready, for example, to run Rounds on staff bullying and harassment, receiving a poor CQC report or making mistakes. There were also differences in facilitators’ confidence levels about being creative with Rounds:

I think because we started doing them [. . .] the format was evolving that I’ve always felt that we had the sense of it’s OK to play with this, right from the beginning.

Ash-400-Facilitator

It often took time for Rounds to feel safe for staff. A facilitator highlighted a doctor who had been in Rounds’ audiences for 6 months before volunteering to be a panellist and share an experience. The story they then told was one of sharing their vulnerability about feeling that they had made a mistake:

I’ve got a doctor watching and then 6 months later offering a Round which was one of our most powerful Rounds because they watched to see how safe it was.

Focus group-Participant 01-14.11.16

Similarly, audience members spoke about how they often attended Rounds several times before building up the confidence to contribute:

It might be that it takes people a few Rounds. They’ve heard something and they’re formulating a thought but they don’t feel confident to be able to say it and then they go to another Round a few months later and by then they go, ‘This is how I feel about it’ and they say it.

Elderberry-06-Panellist

As I went to a few I felt more and more comfortable about sharing some quite personal stuff [. . .] I shared something that was really personal and it felt OK [. . .] you’re not judged there [. . .] when, you get such a wide spectrum of people there [. . .] when some of the doctors and people that I suppose traditionally tend to think they keep it all together [. . .] when they were there making a commitment to it, actually sharing their vulnerability [. . .] ward sisters [. . .] didn’t seem scared to say ‘I found that really difficult’. Or ‘I didn’t think I did that very well’. I think that gives you confidence to think ‘oh it’s OK’.

Willow-37-Attender

These suggest that, for some people, regular attendance at Rounds is a necessary step towards building confidence and trust in facilitators, and in the Rounds structure and process, so that they can follow the examples set by panellists and other contributors and publicly disclose their own similar experiences. The greater the depth of the discussions, the more likely the person is to feel vulnerable. Therefore, the trust built over time among the disclosers (and often among panellists or audience members) and the facilitator/audience is essential to reach deep discussion, which theory suggests produces outcomes (see Chapter 8). In new Rounds sites, or in established sites where the audience is relatively inexperienced or unfamiliar with Rounds, there are differences in levels of audience confidence and trust, so discussions may be relatively superficial.

Intrastructural system

An example of the wider and intrastructural system context that had an impact on Rounds was our participants identifying the felt need for Rounds to support staff (see Chapter 4) in a service with complex emotional work with patients/colleagues and high levels of psychological distress. Interviewees also reported increasing levels of scrutiny, regulation and demand, which, coupled with more limited resources, resulted in staff experiencing higher work intensity and increased levels of stress.

Some case study interviewees identified that in the prevailing culture of health-care organisations – with protocol-driven outcome-orientated care, rigid hierarchies and emotional stoicism – it takes time for staff to adjust to and accept the culture of Rounds as support spaces where emotions are shared (vs. stoicism), where hierarchies are flattened and where there are no explicit outcomes (see Chapter 8, Countercultural/third space for staff).

In terms of the outer context influencing the adoption of Rounds, interviewees in our mapping study suggested that a reason for the adoption of Rounds was to improve patient care by attending to staff well-being through a form of emotional support. This is slightly different from the original aim of Rounds – as developed in the USA – (see Chapters 2 and 4) as an innovation to teach compassion and strengthen the patient–caregiver relationship (see Boxes 3 and 4). Our interview with the PoCF director suggested that, initially, Rounds had been brought to the UK with the same intention, but the increased evidence of a link between staff well-being and patient experiences of care in the UK32,68,77,85 shifted the focus a little, so that attending to staff well-being became more central as an interim outcome: also important in its own right, but also with the ultimate goal of improving patient experiences of care. Interviewees in our mapping study and case studies also cited the Francis report, the dissemination activities of the PoCF and the availability of funding from recognised national charities1 as influences on the adoption of Rounds (see Chapter 4).

Participants

In the UK, Rounds are open only to staff. In a small number of Rounds a patient has been invited to present a story, and the ‘exclusion of patients’, as some people see it, is often controversial. Our interviewees suggested that it was not so much an excluding frame of reference; rather it was about making Rounds a safe place for staff to speak openly without feeling the need to protect or care for patients, as is the norm outside Rounds. This is a key element supporting the concept of a ‘countercultural space for staff’ (see Chapter 8), where Rounds provide opportunities and space outside the realms and demands of their normal role:

So often we put patients at the forefront of everything and that has its place, but we tend to forget the staff. So for me it’s about staff are hugely important too. They’re our biggest asset in the organisation. And Rounds is [. . .] about supporting staff and helping them to think about the impact of situations on themselves to enable them to be better carers.

Ash-05-Facilitator

It really worries me, it sounds extreme, but for me I think places where staff and patients talk together would be incredibly valuable but it wouldn’t be Schwartz Rounds, because I think it’s fundamentally about safety [. . .]. For me that’s [patients in audience/on panel] a major line you just wouldn’t dream of crossing and yet it has been asked of us often and [. . . I] say no quite confidently.

Focus group-22.11.16-Participant-01-Facilitator

Trust, safety and containment

The Rounds model, with ground rules and an emphasis on purpose and what Rounds were not (problem-solving or outcome orientated), was important for creating a safe emotional space for the sharing of stories and reflection:

I think between us, the clinical lead facilitator reminding everybody of the ground rules explicitly, reminding everybody of the purpose, being really rigid about the boundaries, sticking to time, so all the ritual and the content. Being careful to look for everyone to speak, monitoring emotion in the room, protecting the panel members if it feels like it’s moving in a problem [solving] direction, actively intervening to say ‘that’s not our job here’, reminding people of the time as we get towards the end [and of confidentiality], saying things like ‘there may well be emotions and stories that have been stirred up here that you will want to carry on talking about afterwards’, it’s great to do that without mentioning names.

Willow-01-Facilitator

The model and [. . .] how we do train people in the model [. . .] is a huge part of what creates the safety.

Focus group-Participant-04-22.11.16

I think the magic is made in part by the process, by following the process carefully and by always saying the same things always having the same timing always having the same format, I think that gives it a therapeutic sort of holding, but I think the magic happens when [. . .] the audience really engage in the process and are willing to share their own vulnerability and then just amazing things happen.

Mulberry-367-Facilitator

Pre-prepared staff stories

Our data suggest that having the opportunity to pre-prepare stories with the assistance of a facilitator or clinical lead is a core component (although we noted that, in practice, such preparation varied considerably), because all of the facilitators we spoke to felt that it was highly desirable to ensure emotional safety in the Round by pre-preparing panellists and stories and checking that individual panellists were ready to tell their story:

I think we’ve really followed the model here, we’ve done all the preparation which does pay off, [. . .] you don’t want to put the person in the position where they feel very vulnerable, raw and totally exposed.

Elderberry-08-Stakeholder–speaking as a panellist

It seems obvious to me because I follow the Schwartz Rounds model very closely but I am aware [. . .] there are some people who are feeling that it’s a very curious model and that it needs to be much more flexible and so I’ve heard people saying [. . .] ‘I don’t think it’s necessary to practise and we could just do it’, which I find quite alarming [. . .] and I feel [the Round is] safer when [. . .] I know the gist of what people are going to say and I think the other panellists need to know that as well and I do [all the things I was taught by the lead mentor] because I’ve seen that they work.

Focus group-Participant-ID:02-22.11.16

With regard to the adaptable periphery components70 of Rounds, we suggest these in Box 2.

Our data suggest that many of these aspects have been, or are about to be, implemented as adaptations (diversity, duration, number of panellists, scale, regularity, built environment and focus of the story, and live vs. filmed stories). For example, the Rounds we observed were all 1 hour in duration, but we heard of sites that were experimenting with shorter, 30-minute ‘pop-up’ Rounds to ‘take Rounds to those who found it hard to attend’ (ward-based staff). These pop-up Rounds also had fewer panellists and only one facilitator.

We discuss some ‘adaptable periphery’ components (diversity, duration and number of panellists) in the following sections; others are covered in our organisational guide. 86 Other adaptations were suggested and were being trialled at the time of writing as solutions to particular issues [e.g. live vs. filmed (digital) staff stories and Rounds format and scale].

Diversity and duration

The Schwartz Rounds model suggests that Rounds should be open to all staff, and this was true of the majority of the 43 Rounds we observed. Being ‘open to all’ might, therefore, be considered a core component by many, although we observed one unidisciplinary Round, which, on reflection, seemed less powerful, but may have allowed those staff to speak about issues that concerned them, and that might not have resonated with a wider group. Two mentors debated the advantages and disadvantages of running unidisciplinary Rounds in our theory testing group:

I would feel that the multidisciplinary aspect is core just because I think that is one of the things that makes a Schwartz Round different to other spaces because people listen differently when it’s a case that they weren’t involved in or when it’s a profession who they’re different to, it does something to the reflection which allows you to sit back and listen in a slightly different way. I think when you’re in a unidisciplinary space [. . .] they feel different to Schwartz [. . .] and I wouldn’t call it a Round.

Focus-group-Participant-03-22.11.16

I would say differently to you because I have facilitated unidisciplinary Rounds [. . .] and because we kept to the model very clearly with the panel preparation and all the timing, time was shorter, but the model itself was maintained and I think they have a place to play. I would have agreed with you before I did it.

Focus-group-Participant-02-22.11.16

The benefits of ‘unidisciplinary’ and ‘pop-up’ Rounds are that more staff are exposed to Rounds and have an opportunity to speak and hear about the human dimensions of care. The potential disadvantages are that some benefits may be reduced (such as the wider multidisciplinary reflection; shining a light on hidden stories and roles/people in the organisation; and the multiple perspectives of staff) (see Chapter 8).

In one of our case studies (hospice), we learnt how there had been an incident that had led to more specific criteria on whom Rounds are for, to protect and ensure the safety of staff, although we heard that this is not widespread practice among hospices:

The Rounds are for any employee, but we say no to volunteers [. . .] I think we’ve had a number of issues where volunteers have misunderstood what they’ve seen or heard. My feeling is it wouldn’t be a safe environment if you had people who often don’t understand the context. And what we want is staff to be able to feel safe to say anything like, ‘I’m so glad that person died’, or – but if you have people who might misunderstand you and have done in the past, then you wouldn’t feel safe.

Elderberry-01-Clinical Lead

Similarly, we observed one Round where audience members and panellists were invited from an organisation that worked closely with the trust, and this site was considering running Rounds occasionally as a way of increasing communication between partner organisations within their locality. In this Round, we noticed that the increased number of new attenders had an impact on the overall ‘Schwartz savviness’ of the audience, making the Round more difficult to facilitate.

We suggest, therefore, that although adapting Rounds so that they are no longer open to all (e.g. pop-up Rounds or unidisciplinary Rounds) or are opened up to staff outside the host organisation (e.g. who worked in partner organisations) has a purpose, namely to enable more staff to experience Rounds and increase communication and working relationships, this adaptation of one of the ‘core components’ may come at a cost, and requires further evaluation.

Number of panellists

Although the usual number of panellists was three or four, we observed Rounds with one panellist (in the UK) and with six (in the USA). We would suggest that, although the number of panellists is an adaptable periphery component, Rounds should, when possible, have no more than four panellists in order to reduce facilitator workload and allow sufficient time for audience reflection and discussion.

A further comparison of the Rounds case study sites in terms of fidelity to core components of Rounds sites was undertaken (see Appendix 22).

Realist evaluation

Realist evaluation is concerned with the identification of underlying causal mechanisms that explain how an intervention such as Rounds works, for whom it works and under what conditions. Causal mechanisms are always embedded within particular contexts and social processes, meaning that Rounds might work differently in different situations and circumstances. The overarching aim in a realist evaluation is to understand the complex relationship between these mechanisms and the effect that context has on their operationalisation and outcome. This is summed up as context + mechanism = outcome. 4 This is subsequently represented as context–mechanism–outcome (CMO) configuration. The CMO configuration is used as the main structure for realist analysis. 4 It is a heuristic device/proposition detailing what it is about an initiative that works, for whom and in what circumstances, and is used to generate causative explanations. 87 From an iterative analysis process of scrutinising mechanisms, context and outcomes, we propose some theoretically generalisable features about Rounds (i.e. refined CMO configurations)88 (see Report Supplementary Material 9).

Setting and participants

Four members of the research team undertook 177 semistructured interviews with Rounds attendees, facilitators, steering group members and panellists in nine case study sites (see Chapter 6) and observed 42 Rounds in eight case study sites (see Chapter 7; it should be noted that we could not observe Rounds in Horse-chestnut).

Data collection

One of two researchers (ML and ER) led data collection in four or five case study sites from September 2015 to June 2016, supported and supervised by the PI (JM).

Interview and observations

The interviews were initially quite open, with interviewees asked how they understood Rounds to ‘work’, how they identified and explained any changes that generated outcomes, and which aspects of the Rounds process were key mechanisms in this (see Appendix 19). Some interviewees found this easier than others. Subsequent interviews built on mechanisms identified in findings from phase 1 interviews and initial phase 2 interviews (see below). In such a complex intervention, where mechanisms and outcomes are not easily visible (taking place in the minds and later behaviour of participants), interviews with key informants (i.e. experienced audience members, panellists and facilitators, who had thought about how Rounds ‘worked’ and changed behaviour) were most beneficial. Our interviews developed over the data collection period, focusing on one or more key mechanism and testing ideas and theory with new, and at times the same, participants, to explore and test our emerging CMO configurations.

In each case study site, we observed a minimum of four Rounds (43 in total) (apart from Horse-chestnut). Observations were usually undertaken by one member of the team, but two members observed at least one Round in each site to enable them to compare notes and generate discussion. The focus of our observations shifted as data collection progressed and we identified new candidate programme theories to ‘test’. All field-notes captured the number of attendees, the room layout, the number of facilitators, the topic, and the number and role of panellists, and captured the key moments and elements of the Round. As data collection progressed, the team focused on some aspects of Rounds more specifically, for example the facilitator role and how emotional safety was supported or compromised; the use of silence; the use of Rounds ‘rituals’ and rules; and how the audience responded and supported safety in Rounds (or not). We also sought to identify the contexts and specific conditions in different sites that influenced Rounds mechanisms (see Chapter 7).

Data analysis

Realist data analysis is driven by explaining change brought about by an intervention and suggests that programmes offer resources or opportunities, but the decision-making of participants causes the outcomes (it is still necessary for the programme to be implemented as intended for it to be effective; see Chapter 7). 5 Data analysis and data collection were undertaken concurrently and we focused our initial realist analysis on interview data with Rounds key experts to search for CMO configurations to find support for causal explanations.

Interviews were multistaged and served different purposes at different phases: theory gleaning, theory refining, theory testing and consolidating interviews. 8 We drew on our own expertise gained through observing key Rounds stages, such as panellist preparation, Rounds and steering group meetings, to develop, test and refine our candidate programme theories (CMO configurations) (Figure 8).

FIGURE 8.

Data analysis process.

We systematically analysed a selection of key experts’ (facilitators and clinical leads) interviews for CMO configurations and causal explanation (across all case studies), and labelled the CMO components in author comments in Microsoft Word (Microsoft Corporation, Redmond, WA, USA) to enable us to review each other’s CMOs and discuss. Five members of the research team (JM, ML, ER, CT and IM) read and analysed the same four transcripts, and discussed and compared analytic categorisation and notes. The team then analysed up to 10 transcripts each, identified overlap and colour-coded data sections relating to context, mechanism and/or outcome (see Figure 8), and discussed these in 10 half-day meetings, with and without support from Justin Jagosh, our realist methodology expert and mentor. We initially generated 29 CMOs and organised them across the four stages of our Rounds model (see Figure 7), and by key player (audience, facilitator, clinical lead or panellist). Further analysis cycles and testing causative configurations in repeat interviews with our well-informed ‘experts’ and two focus groups with Rounds mentors allowing us to refine and collapse our 29 CMO configurations to the nine presented below. Finally, in meetings with Justin Jagosh, we grouped and causally linked our nine CMO configurations together (see Figure 10).

We revisited our initial programme theory and refined this in the light of our CMO data to develop our evidence-informed programme theory (see below). Report Supplementary Material 10 provides a summary of nine data themes that informed our revised CMOs and their inter-relationships.

Our field notes of observations of Rounds, steering groups and panel preparation were managed and analysed as textual qualitative data. 89 We followed steps 3–6 above for our field notes on Rounds to examine data to confirm or disconfirm our CMO configurations. We organised our data in Microsoft Word files and using some aspects of framework analysis to determine key descriptive elements across panel preparation and Rounds observation field notes, for example the timing and stages of Rounds; where and how facilitators intervened to support panellists or audience members and maintain safety (or not); and, in panel preparation, how facilitators gathered information and supported panellists to craft stories (including safety and trust aspects). We have not been able to include many fieldwork data from Rounds owing to the sensitivity of the material and the challenges of maintaining anonymity and confidentiality.

Programme theory

All programmes or initiatives will (implicitly or explicitly) have a programme theory, or theories,6 about how the programme is expected to cause its intended outcomes.

Specific data used to develop our initial programme theory included our:

• initial review of the literature to identify mechanisms of Rounds to enable us to design our survey (see Chapter 3)

• composite definition of Rounds in our literature review (see Chapter 3)

• interviews with programme architects in the USA (see Chapter 3)

• initial observations of Rounds and discussions with key players in UK implementation

• review of programme documentation including SCCH in Boston and PoCF websites and contracts.

These approaches enabled us to develop initial programme theories about how, for whom, and under what circumstances the Rounds help health-care staff with the human dimensions of their work (Box 3).

When a programme like Schwartz Rounds is implemented, it is testing a theory about what ‘might cause change’ (p. 1), even though that theory may not be explicit. 5 When we started, we found that the theories or mechanisms by which change might occur were not very explicit (see Box 3). Thus, a key task in our realist evaluation was to make the theories within the programme explicit, by developing clear hypotheses about how, and for whom, programmes might ’work’ (see Chapter 3).

Revised evidence-informed programme theory

Box 4 details our refined programme theory, informed by the evidence from our study, through an iterative CMO configuration process, distilling from the configurations how the Rounds (the programme) cause their intended outcomes based on an analysis of our data.

We found that there was less evidence of specific ‘teaching’ than our initial programme theory had implied, although participants spoke of providing learning for others, but we did identify that Rounds strengthen empathy, compassion and relationships between staff, as well as strengthening the patient–caregiver relationship. We also found that visible organisational support had pros and cons (see Chapter 7). Our revised programme theory provided greater insights into how Rounds generated their effects (see above) and we identified some additional mechanisms, including:

• the importance of resonance as well as reflection

• the importance of containment and trust as well as safe and non-judgemental space

• the key mechanism of storytelling and the important role of panel preparation for crafting and telling powerful emotional stories of staff experiences

• that the impact of Rounds develops over time and has a cumulative effect

• the mechanism of contextualising patients and staff and shining a light on hidden roles and stories

• that Rounds provide a countercultural third space (see below).

We now provide a detailed exploration of our refined CMO configurations, which informed the revised programme theory (see Box 4).

Cumulative and linked context–mechanism–outcome configurations

Our findings (CMO configurations) are cumulative and linked.

Cumulative impact of stages of Rounds

In Chapters 6 and 7 we presented our Rounds stages diagram (see Figures 6 and 7). Here we illustrate where our analysis suggests that the nine CMO configurations map across the four stages (Figure 9). It can be seen that not all CMO configurations work across all four stages, with self-disclosure, contextualising patients and staff, reflection and resonance, and group interaction occurring only in panel preparation and Rounds, and not in stage 1.

FIGURE 9.

The CMO configurations mapped to the stages of Rounds.

As well as being a four-stage cycle for each Round, our findings suggest that each stage has a cumulative impact on the next. Thus, temporally, stage 4 of one Round or a series of Rounds has an impact on the early stages of the next Round or Rounds. This is important, as it takes time to establish Rounds and create resources, for example experienced facilitators, trust and psychological safety, and a ‘Schwartz-savvy’ audience.

Linked cumulative context–mechanism–outcome configurations

To illustrate the cumulative impact of Rounds another way, we present how our nine refined CMO configurations are interlinked (Figure 10). Group interaction, and trust safety and containment, which are both core components of the Schwartz Round model, are prerequisites for all other CMO configurations. Storytelling and self-disclosure share similar theoretical processes (e.g. cognitive integration, making sense of experiences), so they have been grouped together, whereas ‘role-modelling vulnerability’, ‘contextualising patients and staff’ and ‘shining a spotlight on hidden roles’ are all examples of what is being offered and revealed as part of the process of self-disclosure and storytelling. Reflection and resonance is triggered by hearing stories and witnessing the self-disclosure of panellists, and, as audience members also share their stories and self-disclose, this creates cumulative effects for future Rounds.

FIGURE 10.

Visual representation of evidence to illustrate how CMO configurations link together to explain how Rounds ‘work’.

Ripple effects may occur as ‘unanticipated outcomes’ or ‘side effects’ of Rounds, because part of the countercultural nature of Rounds is that they are explicitly free from the usual expectations around the identification and allocation of tasks, responsibilities, actions and changes that would normally be part of team meetings or similar interventions such as reflective practice or clinical supervision. Ripple effects occur because individuals, or groups of individuals, decide to act on or take forward initiatives outside Rounds as a result of what they have heard. This can be difficult for new attendees to grasp and, because of the prevailing NHS culture, some attendees felt some frustration that there were no action plans or outcomes. Over time participants reported that they came to appreciate the different space provided by Rounds and realised they could take action: just that it was not a requirement. In terms of the countercultural/third space, we suggest that this is driven by fidelity to the model (not problem-solving; safe and confidential space) also outlined in Chapter 7 and is an accumulation of all of the other CMO configurations, thus making the whole Schwartz Round a countercultural and a ‘third space’ (see below for further explanation). Outcomes are either predicted on the basis of theory (i.e. programme or existing relevant theory) (anticipated) or evidenced by data.

Detailed context–mechanism–outcome configurations

We now present each of the nine CMO configurations in detail. We have separated the resource and response in the mechanisms where applicable. Further supporting data for each CMO configuration are presented in Report Supplementary Material 11.

Intermediate outcomes

Our survey data support the outcomes from this CMO configuration, identifying stress reduction (GHQ-12 ‘caseness’) in Rounds attenders versus non-attenders (see Chapter 5). In interviews, staff reported that the safe, confidential space provided by Rounds enabled them to be better practitioners, to think about their behaviour, to make different future choices and to be more empathic with patients, for example:

[Rounds are] a safe space to discuss things that are challenging [. . .] this enables practitioners to be better practitioners and be more empathic, have a moment to stop and think about themselves and their behaviours and others’ behaviours, and that reflection may help [. . .] in the future.

Juniper-11-Panellist

Our data support other work that suggests that some mechanisms operate on a continuum, like a ‘dimmer switch’, rather than simply the mechanism ‘firing’ or ‘not firing’. 91 Contextual factors that turn up this mechanism’s dimmer switch include the extent of panel preparation, the facilitator’s skill and/or experience, and the audience’s Schwartz savviness (see Chapter 7).

Theory suggests that containment provides a sense of safety for the panellist and audience members to explore feelings that may otherwise be experienced as overwhelming and confusing. It is often about ‘holding’ the alarm, confusion and pain of unfamiliar or overwhelming feelings, and can be described as the capacity of one person to stay with, and psychologically and emotionally hold, the distress of another person in such a way as to allow it to be coped with. 92 It requires the facilitator to manage their own sense of uncertainty and confusion in order to be effective in helping those in Rounds to manage their own feelings. The facilitator needs to provide the confidence and presence to enable panellists and Rounds attenders to believe that their difficult feelings can be managed, explored and understood to avoid unsatisfactory coping mechanisms. 93 Confidentiality is crucial if members are to take risks necessary for real growth;37 our data provided evidence to support these theories:

It’s set up to be a safe, confidential forum [. . .] I mean often it’s come to my mind about using a psychotherapy term of ‘containment’ but a place for people to express their feelings, some containment both from the panel and other people in the audience, to understand the emotional reaction to it, for it to be OK to express feelings that might seem strange, unacceptable, awful. [. . .] some understanding about why people are feeling that way

Anonymised-site-17-Panellist-speaking-from perspective-of-facilitator/psychiatrist

Literature review

We reviewed the Schwartz Rounds literature to identify the key features of Rounds and created a composite definition to aid comparison with alternative interventions. Eleven alternatives were identified, each of low to moderate quality and limited evidence base. By comparison, Rounds offer a unique organisation-wide open staff forum to reflect on the emotional impact of providing patient care that no other alternatives provide. We found that the few published research evaluations of Schwartz Rounds were also of low to moderate quality (weak study designs without control groups), but the findings indicate self-reported positive impact on individuals, their relationships with colleagues and patients, and wider culture changes. We identified key mechanisms by which Rounds may have an impact (reflection, group work, disclosure and safe environment), which we tested in our realist evaluation. We identified seven guiding principles underlying Schwartz Rounds from interviews with programme architects in Boston, MA, which contributed to the initial programme theory of how Rounds work.

Mapping Rounds providers

Our mapping data (interviews, online survey and secondary analysis) found that most providers were NHS trusts (n = 86, 75%) and hospices (n = 25, 22%). Almost half of all acute trusts in England had adopted Rounds by July 2015 (44%), which is greater than Rounds adoption by mental health/learning disability trusts (26%), community trusts (18%) or hospices (13%). Of the 115 organisations running Rounds in England at 15 July 2015, over half were based in the south of England, with over one-quarter of all providers in London. We found considerable variability in the resourcing of Rounds; the median staff cost for a small organisation was £650 per month, whereas for a medium or large organisation the cost was £2000 per month. There was variability in how Rounds were implemented, and challenges to implementation and sustainability were attendance (particularly ward staff, those with less autonomy), and the workload and resources required for planning and running Rounds.

Staff survey

A two-wave survey (8 months apart) of new Rounds attenders and non-attenders was undertaken in 10 sites. Five hundred staff responded at both time points: 51 were regular attenders, 205 were irregular attenders and 233 were non-attenders (11 could not be categorised).

Our primary hypothesis (that work engagement is positively associated with attendance at Rounds) was not supported. However, the incidence of GHQ-12 ‘caseness’ (minor psychiatric disorders) dropped significantly for regular attenders compared with non-attenders, with evidence to suggest that attending more Rounds led to greater improvement.

Realist evaluation

We identified multiple, interconnected contextual layers that have an impact on and explain variation in Rounds implementation. These included the individual capabilities and characteristics of key actors (e.g. facilitators); support given by the core team and steering group; length of time running Rounds; audience characteristics (size, composition and diversity); Rounds characteristics (theme or case based); and the wider health-care and policy context for Rounds. Our data support other work that suggests that some mechanisms operate on a continuum, like a dimmer switch. 91 Favourable contextual conditions that activated the ‘trust, emotional safety and containment’ mechanism, for example, included the presence of safety checks in panel preparation; the level of facilitator skill, confidence and/or experience (knowing how to intervene when required, not reprimanding the audience and/or no repercussions); and the extent to which the audience had developed a Schwartz-Rounds savviness (knowing how to contribute in a way that supports facilitators in keeping Rounds safe).

We identified four stages of a Round with different stages having a cumulative impact on subsequent Rounds (e.g. organisational longevity of providing rounds, a ‘Schwartz-savvy audience’; audience trust and confidence, facilitator experience and confidence). We identified which components were ‘core’ in terms of fidelity (e.g. senior clinical leadership, facilitation, regularity, food available, focus on emotional impact, and only staff participants) and which were ‘adaptable’ (e.g. duration, number of panellists and Rounds format).

We also identified nine cross-cutting and interlinking themes represented as CMO configurations, namely (1) trust, emotional safety and containment; (2) group interaction; (3) a countercultural third space for staff; (4) self-disclosure; (5) storytelling; (6) role-modelling vulnerability; (7) contextualising patient, carer and staff behaviours; (8) shining a spotlight on hidden organisational stories and roles; and (9) providing an opportunity for reflection and resonance. Rounds offer an opportunity for organisations to have a community conversation and for staff to speak honestly and openly about their experiences of delivering health care. Our realist analysis suggests that the Rounds impact develops over time and has a cumulative effect resulting in ripple effects and outcomes (e.g. greater insights and increased empathy and compassion for colleagues and patients; support for staff; reduced isolation; improved teamwork and communication; and reported changes in practice). We identified some examples of ripple effects felt in day-to-day practice across the organisation (e.g. changes to protocols, changes to culture and conversations, and the set-up of support groups for specific staff), but we did not shadow staff to observe these.

Staff experiences

Our interview participants (n = 177) largely described Rounds as interesting, engaging and a source of support. Participants valued the opportunity to reflect and mentally process work challenges and learn more about colleagues and their management of challenging patient cases. This led to greater understanding, empathy and tolerance towards colleagues and patients. A few questioned the purpose of unearthing feelings of sadness, anger and frustration, and felt that the outcomes of Rounds were neutral or negative. We identified enablers of (e.g. convenient location and freedom over schedule) and barriers to attendance (e.g. conflict with other clinical priorities). Sufficient administrative support and an active steering group were key to supporting and sustaining Rounds, but these varied between sites. Key challenges were maintaining motivation and enough resources to sustain Rounds.

Overall outcomes

We have noted above, and in the preceding chapters, some of the reported outcomes identified by Rounds participants and others in this study. We have also noted that it was not possible to observe ‘outcomes’ by shadowing staff and that Rounds themselves are not outcome orientated, nor do they encourage problem-solving. However, we did identify a number of organisational ‘ripple effects’ (changes in protocols and conversations were reported, as were the setting up of new support groups), and our participants noted a number of changes to self (greater self-compassion, more reflective, more open to emotional aspects of their work and to learning from others) and to their own and others’ behaviours (changing how they work with patients, trying something new, being open to challenge from others and being prepared to challenge colleagues). It is worth noting that ‘O’ in CMO is ‘altered state of attendee’, which is the outcome of focus of the report, and we have noted throughout the report, and summarise in Table 27, these altered states and related reported outcomes, such as improved psychological well-being (attendee survey). Through our realist evaluation interviews we have noted the increased empathy; compassion for self and other staff, patients and carers; increased openness and honesty; increased resilience; improving teamwork; and changing the culture of the organisation. It is also important to note that Rounds did not ‘work’ for everyone, and that some attendees questioned the purpose of Rounds and noted no or negative outcomes for them personally.

Literature review

The strengths of this review are the inclusion of all literature regarding Schwartz Rounds (including non-empirical literature), enabling our composite definition and features for comparison with other interventions to be based on a hybrid UK/USA literature base. The comparison of Rounds with alternative interventions provides a framework for managers/providers to examine and compare the different staff support/well-being interventions they may offer or be considering implementing. However, the breadth of the review of alternative interventions was considerable. As we developed our understanding of which mechanisms have an impact on Rounds, through our realist analysis, we realised that we could have restricted the number of alternatives to Schwartz Rounds to those that shared the most similarities. Conducting a realist synthesis of Schwartz Rounds and their alternatives, rather than a scoping review would have been a beneficial precursor to the realist evaluation to further help us develop our candidate programme theories. It is also possible that our review did not capture some of the literature, although our use of multiple search strategies aimed to minimise this.

Despite a major review of the well-being of the UK NHS workforce in 2009,32 we continue to lack evidence regarding the most effective intervention strategies owing to the poor quality of the evidence base as highlighted by previous reviews127–130 and confirmed in our scoping review.

Maintaining staff well-being requires strategies and interventions aimed at individuals and organisations. Organisational-level interventions for staff well-being are scarce, with attention primarily focused on prevention or treatment at an individual level (e.g. stress management or counselling interventions). 129 Evidence shows that interventions aimed at behaviour change – a critical feature of many staff support interventions – are more likely to be effective if tackled from multiple levels (individual, organisational and wider society). 131,132 We have shown that Rounds are unique in providing an intervention that straddles the individual and organisational levels.

Mapping survey and telephone interviews

To our knowledge, this is the first attempt to describe variation in implementation of Rounds and has highlighted differences in how Rounds are run and resourced, but also consistency across providers in relation to key challenges despite these contextual differences. The variability in implementation is unsurprising given the evidence of the ‘implementation gap’ and variation in adherence to guidance across health care generally, highlighting the complex interplay of factors affecting ‘supply’ and ‘demand’ – and thereby the importance of contextual factors. 133

The use of a range of data sources enabled an up-to-date report of the implementation of Rounds in England, although our detailed profiles (based on survey and interview data) were necessarily based on the subsample of providers running Rounds when we commenced our evaluation. The main limitations here concerned difficulties obtaining R&D approvals. This was an onerous task and we faced considerable delays in getting permission, which limited our sample size. Furthermore, some mapping survey data were poorly completed, inaccurate or difficult to interpret, especially the cost/resource data. We addressed this by requesting clarification from a subsample – purposively selected to represent different size/types of organisations – to help complete, correct and interpret data.

Staff survey

This study is the first to use a longitudinal design with a control group to evaluate Rounds. The sample of 500 participants providing data at both time points enabled an examination of relationships with engagement, psychological well-being and intervening mechanisms, using a clinically well-validated measure of psychological wellbeing (GHQ-12). In contrast to previous studies, we were able to demonstrate a clear association between Rounds attendance and subsequent psychological well-being.

One key limitation was that we had a smaller than desired sample of regular attenders (and for some outcomes, data excluded staff without regular patient contact, resulting in smaller samples still). The resultant lower power may explain, at least partially, why more significant differences between attenders and non-attenders were not detected. In addition, some of the measures may not have been sufficiently sensitive to change, or robust enough to capture any differences that may have occurred. For example, any changes that may have occurred outside the direct influence of the attender (e.g. peer support) may see very little change. The self-report nature of the questionnaires, combined with self-selection into the attender group, may have led to positive evaluations and ‘ceiling effects’ in the baseline survey, giving less opportunity to improve at follow-up. In addition, there were clear baseline differences between the groups of regular attenders and non-attenders, with regular attenders typically being more senior and more likely to come from medical professions. Although we control for this as far as possible in the analysis, it is impossible to remove the confounding completely. Furthermore, this analysis necessarily treated all Rounds as equal, whereas no two Rounds are the same (see Table 28).

Realist evaluation

The strengths of our work include the variation in case study sites (purposively sampled to reflect issues that affected context), the number of Rounds we observed, the number of interviews and their depth and breadth. Finding staff to interview who stopped attending Rounds was challenging, and despite using a number of methods to source participants who were negative about Rounds, we found only a few. Our data suggested practical reasons people stopped attending or found it hard to attend. In terms of limitations, our case study observations did not include an observation of mentor–facilitator/clinical lead debriefing and support meetings, providing an opportunity for facilitators/clinical leads to reflect on where Rounds sit within the wider organisational context, which could have provided further data on contextual variations between sites.

It was not possible to observe ripple effects of Rounds (actual changes that occurred as the result of attending Rounds) because interviewees found it very hard to identify concrete examples of changes in practice that could be observed.

Journal publications

Taylor C, Xyrichis A, Leamy MC, Reynolds E, Maben J. Can Schwartz Center Rounds support healthcare staff with emotional challenges at work, and how do they compare with other interventions aimed at providing similar support? A systematic review and scoping reviews. BMJ Open 2018;8:e024254.

Robert G, Philippou J, Leamy M, Reynolds E, Ross S, Bennett L, et al. Exploring the adoption of Schwartz Center Rounds as an organisational innovation in England to improve staff wellbeing in England 2009–2015. BMJ Open 2017;7:e014326.

Oral conference presentations

Leamy M, Maben J, Taylor C, Reynolds E. Supporting NHS Staff at Work: What are Schwartz Rounds and How do They Work? Early Findings from a National Research Study, The Caring Organisation: Enabling Compassion to Flourish. Point of Care Conference, Royal Society of Medicine, London, 16 December 2015.

Robert G, Philippou J, Ross S, Bennett L, Taylor C, Reynolds E, et al. Supporting the Wellbeing of Staff and Improving Compassionate Care: Exploring the Adoption of Schwartz Centre Rounds in the United Kingdom, 2009–2015. National Institute for Health Research Health Services and Delivery Research Conference, Nottingham, 13–14 July 2016.

Maben J. The Links Between Staff and Patient Experience of Hospital Care: A UK Perspective. Invited presentation. Presentation to Faculty of Health Sciences, Murdoch University, Perth, WA, 25 August 2016.

Maben J. Schwartz Rounds. Presentation to Sir Charles Gairdner Hospital. Invited presentation. Perth, WA, 31 August 2016.

Leamy M, Reynolds E, Taylor C, Maben J. Ongoing Learning and Reflections from Undertaking a Realist Evaluation of Schwartz Rounds: A Health-Care Intervention to Promote Compassionate Care. Invited presentation. Second International conference on Realist Evaluation and Synthesis: Advancing Principles, Strengthening Practice, London, 2–6 October 2016.

Leamy M, Maben J. Schwartz Rounds: Origins, Early Development and Implementation in the USA and UK. Point of Care Foundation Conference, Senate House, London, 27 October 2016.

Maben J, Leamy M. Schwartz Rounds: Realist Evaluation Draft Findings from National Research Study. Point of Care Foundation Conference, Science Museum, Manchester, 24 November 2016.

Taylor C, Maben J. Schwartz Center Rounds to Enhance Compassionate Care: Results from a UK Mapping Survey. European Oncology Nursing Society conference, European Cancer Congress, Amsterdam, 27–30 January 2017.

McCarthy I, Dawson J, Maben J, Taylor C, Leamy M, Reynolds E, Shulham C. Schwartz Center Rounds®: An Intervention to Support Employee Well-being. British Psychological Society Division of Occupational Psychology Annual Conference, Stratford-upon-Avon, 10–12 January 2018.

Maben J, Taylor C. (On behalf of the project team.) UK National Evaluation of Schwartz Rounds: Launch of Film and Organisational Guide. Invited presentation. Point of Care Schwartz Conference, London, 23 January 2018.

Maben J, Taylor C. (On behalf of the project team.) UK National Evaluation of Schwartz Rounds: Launch of Film and Organisational Guide. Invited presentation. Point of Care Schwartz Conference, Manchester, 6 February 2018.

Maben J (Keynote.) Enhancing Compassion in Relationships Between Staff and Patients: A National Evaluation of Schwartz Rounds in the UK 2014–2017. National Schwartz Rounds Conference, Dublin, 28 February 2018.

Maben J. (Keynote) Enabling and Supporting Staff to Care Well. Humanising HealthCare conference, Point of Care Foundation, London, 28 March 2018.

Maben J, Dawson J, Leamy M, Taylor C, Reynolds E, Shuldham C, et al. Schwartz Center Rounds®: A UK Evaluation of a Complex Intervention to Support Health-care Staff Deliver Compassionate Care. Royal College of Nursing International Research Society conference, Birmingham, 16–18 April 2018.

Maben J, Leamy M, Taylor C, Reynolds E, Shuldham C, McCarthy I. Learning and Reflections From a Realist Evaluation of Schwartz Rounds® – An Intervention to Promote Compassionate Care. Royal College of Nursing International Research Society conference, Birmingham, 16–18 April 2018.

Maben J, Dawson J, Leamy M, Taylor C, Reynolds E, Shuldham C. A Realist Evaluation of Schwartz Center Rounds®: An Intervention To Support Compassionate Care in Health-care Staff. WELL-Med 3 Conference, Thessaloniki, 9–13 May 2018.

Taylor C, Ross S, Phillipou J, Robert G, Leamy M, Reynolds E, et al. The UK Implementation of Schwartz Rounds: An Intervention to Improve Care Through Enhancing Staff Well-being. WELL-Med 3 Conference, Thessaloniki, 9–13 May 2018.

McCarthy I, Dawson J, Maben J, Taylor C, Shuldham C, Leamy M, Reynolds E. The Impact of a Social and Emotional Workplace Intervention on Employee Psychological Well-being. Institute of Work Psychology Conference, University of Sheffield, Sheffield, 19–21 June 2018.

Maben J, Dawson J, Leamy M, Taylor C, Reynolds E, Shuldham C, et al. (Keynote.) Schwartz Rounds as Response to Moral Distress. What is Moral Distress in Nursing? How, Can and Should we respond to it? Public engagement event, Wellcome Trust, 21 June 2018.

Taylor C, Maben J, Dawson J, Shuldham C, Foot C, et al. The Emotional Impact of Care. ‘Time to Talk’ conference, Hampshire Hospitals NHS Foundation Trust, 25 June 2018.

Poster conference presentation

Leamy M, Reynolds E, Taylor C, Maben J. Ongoing Learning and Reflections from Undertaking a Realist Evaluation of Schwartz Rounds: A Healthcare Intervention to Promote Compassionate Care. Poster presentation. 2nd International Conference on Realist Evaluation and Synthesis: Advancing Principles, Strengthening Practice, London, October 2016.

Blogs

Maben J. How Can we Support Healthcare Staff to Care Well? A National Evaluation of Schwartz Center Rounds®. National Institute for Health Research; 23 January 2018. URL: www.nihr.ac.uk/blogs/how-can-we-support-healthcare-staff-to-care-well-a-national-evaluation-of-schwartz-center-rounds/7765

Maben J. Enabling and Supporting Staff to Care Well. The Point of Care Foundation; 30 April 2018. URL: www.pointofcarefoundation.org.uk/blog/enabling-and-supporting-staff-to-care-well/

Organisational guide

Maben J, Leamy M, Taylor C, Reynolds E, Shuldham C, Dawson J. Understanding, Implementing and Sustaining Schwartz Rounds: An Organisational Guide to Implementation. London: King’s College London; 2018. URL: www.surrey.ac.uk/content/schwartz-organisational-guide-questionnaire

Media output: 9-minute research film

Maben J, Taylor C, Leamy M, Shuldham C. (On behalf of the project team.) Understanding Schwartz Rounds: Findings from a National Evaluation. © 2018 King’s College London. URL: https://youtu.be/C34ygCIdjCo

Primary studies

• Arvidsson et al. 227

• Ardvidsson et al. 228

• Ashmore et al. 229

• Begat and Severinsson. 230

• Bogo et al. 231

• Bondas. 232

• Bradshaw et al. 233

• Brunero and Lamont. 234

• Buus et al. 235

• Danielsson et al. 236

• Davey et al. 237

• Davys and Beddoe. 238

• Edwards et al. 239

• Edwards et al. 240

• Flackman et al. 241

• Gonge and Buus. 242

• Gonge and Buus. 243

• Hallberg. 244

• Hallberg. 245

• Hall-Lord et al. 246

• Hansebo and Kihlgren. 247

• Heaven et al. 248

• Holmlund et al. 249

• Hyrkas. 250

• Hyrkas. 251

• Jones. 252

• Jones. 253

• Kelly et al. 254

• Kennedy et al. 255

• Kenny and Allenby. 256

• Kilcullen. 257

• Knox et al. 258

• Koivu et al. 259

• Koivu et al. 260

• Koivu et al. 261

• Lakeman and Glasgow. 262

• Lantz and Severinsson. 263

• Lindgren and Athlin. 264

• Lindgren et al. 265

• Magnusson et al. 266

• Malin. 267

• O’Connell et al. 268

• Odling et al. 269

• Olofsson. 270

• Olsson. 271

• Palsson et al. 272

• Pesut and Williams. 273

• Saarikoski et al. 274

• Severinsson and Hallberg. 275

• Sirola-Karvinen and Hyrkas. 276

• Sloan. 277

• Walsh et al. 278

• White et al. 279

• White and Winstanley. 280

• Williams and Irvine. 281

Secondary studies (literature reviews)

• Brunero and Stein-Parbury. 282

• Butterworth T et al. 283

• Dawson et al. 284

• Ducat and Kumar. 285

• Farnan et al. 286

• Henshaw et al. 287

• Kilminster and Jolly. 288

• Pearce et al. 289

• Wheeler and Richards. 290

Definition

Disclosure is the action of making new, or secret, information known. In psychological terms, it is the ‘social sharing of emotion’. 39

Sidney Jourard was a pioneer in the field of self-disclosure. He hypothesised that human beings can achieve health and the fullest personal development only when they take the risk of being themselves with others:

You cannot collaborate with another person toward some common end unless you know him. How can you know him, and he you, unless you have engaged in enough mutual disclosure of self to be able anticipate how he will react and what part he will play?

p. 3336

Theories regarding how disclosure works: conditions that allow disclosure to happen and responses to it

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.

Stressors can cause emotional disturbance by challenging people’s basic and often optimistic beliefs about self and the world, such as sense of control, self-worth and coherence. 46 There are two important processes in the writing or talking about a traumatic event:

1. the need to construct a story or explanation of an event

2. the importance of labelling emotions. 35

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 Pennebaker43 argues that using language to label an emotion/experience creates a structure, which facilitates understanding of the event. Similarly, Lepore et al. 46 examined the effect of disclosure on adjustment to emotional stressors and, specifically, the mechanisms by which the disclosure supports emotional adjustment. Lepore et al. 46 put forward two hypotheses. The completion hypothesis postulates that putting one’s experiences into language allows individuals to impose a narrative around it, making it comprehensible to themselves and others. Responses from a supportive audience may suggest ways of coping, or reframe the experience more positively. This should allow the individual to adjust to the experience. The desensitisation hypothesis argues that expressive acts allow people to form new associations with trauma-related stimuli. The results of Lepore et al. ’s46 study most strongly supported the completion hypothesis. Conversely, actively inhibiting our thoughts and feelings ‘gradually undermines the body’s defences’,35 which leads to reduced physical well-being (p. 13). 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 anticipation of negative interpersonal responses to disclosure (e.g. labelling, judging). 47 Following on from this, the benefits of disclosure vary according to the listener’s response. 45,46,48 Chaudoir and Fisher45 developed the disclosure processes model to assist individuals in maximising the likelihood of benefit from disclosure. 45 A framework with which to examine when and why interpersonal disclosure was put forward. The five main components of the process are:

1. antecedent goals:

   1. approach-focused goals (e.g. to pursue positive outcomes such as educating others, understanding, and stronger relationships)

   2. avoidance-focused goals (e.g. prevent negative outcomes such as social rejection and conflict)

2. the disclosure event itself:

   1. content (e.g. emotional; depth)

   2. reaction from confidant (e.g. supportive vs. unsupportive)

3. mediating processes: alleviation of inhibition, social support, changes in social information

4. outcomes:

   1. individual (psychological, behavioural, health)

   2. dyadic (trust)

   3. social/contextual

5. feedback loop.

Nils and Rimé48 also tested a model of when and how sharing emotions is beneficial. They identified two responses to disclosure:

1. empathic mode – expected to buffer emotional distress temporarily (feel better)

2. reframing mode – anticipated to grant emotional recovery (basic assumptions positively modified).

However, when the disclosure of events is invalidated, any benefits may be diluted. 46

Application of disclosure theories to Rounds

Drawing on the disclosure theories above, Rounds focus on non-clinical aspects of the patient–caregiver relationship, not problem-solving, and allow individuals to share difficult, challenging and rewarding experiences. Rounds allow individuals to disclose emotional experiences; greater health benefits ensue following sharing of emotions and thoughts rather than sharing facts. Round attendees and panellists are encouraged to be open and honest and discuss their experiences, thoughts and feelings – using language to help understand their emotional response to an event/experience. Effective facilitation by the facilitator/clinical lead can help individuals (re)frame and label their emotions, and thus begin to process and understand them.

The benefits of disclosure vary according to the listener’s response to it. Group interventions mean it is difficult to control others’ reactions to what has been disclosed. However, Rounds are designed to be a safe, confidential space where staff can share their experiences without fear of blame or judgement.

Definition

For effective reflection, group work and disclosure, a safe environment is a prerequisite. Buggins337 argues that space to think, review and learn from experiences should be provided in care settings. It should be a place to unburden and to think about the ‘unconscious processes at work in oneself, the team and the patient population’. 337 This space needs to be regular, dedicated to the task of reflection and properly facilitated.

Theories regarding how a safe environment works: conditions that allow a safe environment to develop and responses to it

Application of emotional safety theories to Rounds

Drawing on the emotional safety theories above, in Rounds the panellist and audience need to feels emotionally safe to share their story/experience without fear of reprisal or blame. Facilitators foster a sense of psychological safety in the Round through their skills in facilitation, group work and psychological insights. Ground rules and the use of an established protocol for Rounds help to create a confidential and safe environment that, together with a sense of community, is necessary for Rounds to work. The experiences shared are contained as a result of the clear boundaries established. Psychological barriers to reflection in a Round, such as fear of judgement and criticism, may be overcome if the Round is set up as per the established protocol (see Fidelity to the Schwartz Rounds model in Chapter 7). This creates a safe, confidential space for sharing experiences and for reflection.

Definition

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 regarding how reflection works: conditions that allow reflection to happen and responses to it

Theories of reflection as a structured learning activity have been put forward by Dewey54,338 (the founder of experiential learning), Kolb55 (cycle of experiential learning) and Schon36 (the ‘reflective practitioner’). They argue that reflection is a rational act and although emotion is a trigger or catalyst for reflection, its role is limited. In their theories, questions are answered and knowledge is created.

Dewey338 linked reflection and action to create new knowledge. He posited five phases/aspects of reflective thought (cited in Giles and Eyler pp. 79–80):339

1. suggestions

2. intellectualisation

3. the hypothesis

4. reasoning

5. testing the hypothesis in action.

According to Dewey,338 ‘the function of reflection is to bring about a new situation in which the difficulty is resolved, the confusion cleared away, the trouble smoothed out, and the question it puts is answered’ (p. 100).

Kolb’s55 cycle of experiential learning defined learning as ‘the process whereby knowledge is created through the transformation of experience’ (p. 38). In his model, learners move through a cyclic experience from feeling (experience) to watching (reflection) to thinking (learning/concluding) to doing (planning/trying out what you have learned). (Concrete experience → reflective observation → abstract conceptualism → active experimentation.)55

Schon36 explored ‘reflective practice’ and wrote about the ‘reflective practitioner’, that is, ‘the capacity to reflect on action so as to engage in a process of continuous learning’ (pp. 102–4). He distinguished between ‘reflection-in-action’ and ‘reflection-on-action’. Reflection-in-action refers to thinking about something while engaged in doing it (concerned with practising critically). Reflection-on-action occurs after the activity has taken place when you are thinking about what you (and others) did, judging how successful you were and whether or not any changes to what you did could have resulted in different outcomes. Together, these form a reflective process for decision-making and professional growth.

More recently, psychologists and sociologists, including Lazarus,56 Mezirow57 and Goleman,58 have argued that emotion plays a central role throughout the reflective process and that emotion cannot be separated from learning. Linking to the disclosure literature already discussed, through reflective practice we can label the emotions involved in an experience and learn from them.

Lazarus56 argues that emotions cannot occur without ‘cognitive appraisals’. The term ‘cognitive appraisal’ highlights the complex, judgemental and conscious process that must often be involved in appraising an event. In this process, individuals respond to an experience by asking, implicitly or explicitly, the following questions:

1. How relevant is this event for me? Does it directly affect me or my social reference group? (relevance)

2. What are the implications or consequences of this event and how do these affect my wellbeing and my immediate or long-term goals? (implications)

3. How well can I cope with or adjust to the consequences [of this event]? (coping potential)

4. What is the significance of this event with respect to my self-concept and to social norms and values? (normative significance)

Scherer et al. (p. 94)340

Individual responses to these questions dictate the labelling of the emotion involved in the experience.

For example, Mezirow57 defines transformative learning as the process of individual critical reflection followed by the sharing of ideas with others to validate insights and culminates in action taken on the individual and collective reflection. Mezirow asserts that examining our outlook on the world, and challenging the assumptions and preconceptions underlying our values and beliefs, can be emotionally threatening. Conversely, he suggests that self-reflection can empower us to be more open and emotionally capable of change.

Emotional intelligence is said to be a highly complementary theory to reflective practice. 58 Self-awareness and emotional growth increase through the development of interpersonal and intrapersonal skills and social relationships. For emotional intelligence, individuals need to understand not only themselves, but also others and their feelings. As such, empathy is key to emotional intelligence. 59 For a person to ‘grow’, they need an environment that provides them with genuineness (openness and self-disclosure), acceptance (being seen with unconditional positive regard) and empathy (being listened to and understood). 60