Below we present a narrative summary of our findings; we also summarise our findings and reported outcomes alongside our aims and objectives in Table 27.
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.91Favourable 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
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.