Contextual factors influencing variation in implementation and outcomes of Rounds

Chapter overview

Realist evaluation is a theory-driven evaluation that involves identifying causal explanations of how interventions work, for whom and under what circumstances. Causal mechanisms are always embedded within particular contexts and social processes, so that Rounds might work differently in different situations, and, as a result of different contexts, trigger mechanisms that generate outcomes. Pawson and Tilley4 sum this up as context (C) + mechanism (M) = outcome (O). In realist evaluation, therefore, one key aim is to understand the effect that context has on how an intervention works: how context can act as a ‘dimmer switch’ to turn up or down the effects of mechanisms. In this chapter and Chapter 8, we report the key findings from our realist evaluation. We build on some of the themes introduced in Chapter 6 and introduce layers of context that fire mechanisms and lead to outcomes, as described in Chapter 8.

We present our findings as follows:

• contextual layers of Rounds – four layers of contextual factors that have an impact on the effectiveness of an intervention
• fidelity to the Schwartz Rounds model – implementing the intervention as intended and comparing case study similarities and differences
• characteristics of ‘successful’ and ‘unsuccessful’ Rounds.

Objectives

We aim to understand whether or not and how Rounds ‘work’ in the UK, for whom and in what contexts (objective 12) to inform decisions about their implementation in other contexts, and to understand what is causing variations in implementation or outcomes.

In this chapter, we examine how Rounds are operationalised, in particular:

• the influence of variance in facilitation (objective 11b)
• the topics presented and Rounds climates (objective 11c)
• the factors influencing ‘success’, or otherwise, of Rounds in organisations (objective 11d).

Methods and analysis

This chapter draws on data from our case studies, two theory-testing focus groups, and our mapping interviews, as described in Chapters 3, 4, 6 and 8. A thematic analysis, informed by realist theory, was used to identify patterns in the data, which were used to undertake a cross-case analysis to identify the contextual layers. Chapter 8 has more details on realist methodology.

Contextual layers of Rounds

Pawson83 and Pawson et al.84 identified four contextual layers that influence variation in outcomes:

1. the individual capabilities and characteristics of key actors taking Schwartz Rounds forward (e.g. values, roles, knowledge and purpose)
2. interpersonal relationships – behind-the-scenes support given by the core team and steering group (e.g. communication, collaboration and networks)
3. the organisational setting (e.g. the reasons for the adoption of Schwartz Rounds, organisational cultures, senior leadership support, audience characteristics, resource allocation, local priorities)
4. the intrastructural setting (e.g. prevailing NHS cultures and staff experiences at work).

We draw on these four layers to present our context findings.

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.

Facilitators’ background, experience, skills, knowledge and training

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

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

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

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

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

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

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

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

Facilitators’ passion, understanding and belief in Rounds

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

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

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

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

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

Facilitator and clinical lead style

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

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

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

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

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

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

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

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.

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

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

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

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

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

Organisational setting

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

• organisational factors
• time running Rounds
• audience characteristics
• Rounds’ characteristics.

Organisational factors

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

Motivations for adoption

In our case study sites, three reasons were given for adopting Rounds: (1) they fitted with existing organisational vision and activities; (2) they were seen as a useful vehicle for promoting desired organisational change and (3) they offered a means of addressing an unmet need for staff support (see Chapter 4 and Table 25). Two sites introduced Rounds because of the clear alignment with their existing organisational vision and activities:

The director of workforce and organisational development e-mailed back and said ‘the trust is trying to do some wider scale work around compassionate employer and this dovetails with it really nicely’, she said ‘yeah, I’d like to take this to the board and champion it’ and then went to the chief executive, they supported it and that’s how it got picked up really.

In contrast, two others had seen Rounds as a vehicle for organisational change:

I’d joined that team [. . .] there were still a lot of problems, culturally, [. . .] it felt like people were disconnected from the emotion of what they were doing a bit and I think that was pressure as well, it was a way of managing people’s feelings, [. . .] people often close themselves down, that’s a way to get through every day isn’t it, and I would say that would be an observation I’d have made.

Perceptions about organisational culture

Organisational readiness for Rounds differed. One facilitator felt that her organisation had decided ‘to take a leap of faith’ in adopting Rounds, and described the right conditions for adoption:

Right at the beginning, we were all finding our way there was a lot of freedom but the organisation was ready [. . .] there was a right mixture of authority and legitimising it and freedom I think.

In a few sites, participants specifically commented on their perceptions of the (lack of) fit between their organisation’s culture and Rounds, suggesting that they were perhaps less ready to adopt Rounds (e.g. Cherry, Horse-chestnut and Juniper). In one of our new case studies, steering group members reflected on a particularly difficult Round:

Senior leadership support

In our case study sites, senior leadership support was broadly provided in four ways: by board-level senior managers (1) pledging their support for Rounds, (2) visibly demonstrating their support by attending and presenting at Rounds, (3) financially, by agreeing to fund adoption and implementation, and (4) practically, by telling managers to put in place measures to encourage and support their staff’s attendance (Table 26).

Round organisers considered the extent to which they were held accountable by their senior management in justifying the existence of Rounds within their organisation. Overall, accountability was fairly light touch. Some senior stakeholders explained that they might begin to ask questions about the feasibility of running Rounds if attendance numbers became a problem:

If the attendance fell off (below 20, on consecutive occasions), I wouldn’t stop them, but I’d ask the question ‘what are we doing wrong?’.

The chief exec[utive] has said that you can have an hour of your working time to spend once a month, to come together to share your stories. And if we don’t use that then it will disappear.

In some sites, the clinical lead sat on the trust board, which had advantages:

I think in principle it has been useful and it has actually allowed me to be an advocate for Schwartz on the board [. . .] and I think it would be quite useful when it comes to arguing for continued funds.

In the majority of case study sites, attendance among senior staff was sparse, although there were exceptions. In Sycamore, we found an exceptionally high level of senior management support, with senior staff attending and contributing regularly, and using Rounds strategically:

I remember our first Round all the executive directors attended [. . .] and other things happened in that it coincided with us as an organisation going through some very difficult times operationally [. . .] We spoke to our chief exec[utive] about it, our deputy chief exec who was in charge of operations was also on the Round, together with lead nurse and senior clinicians in the organisation, so we used the Rounds to have conversations about big problems and we saw the impact of that. I think word of mouth spread and non-executive directors were encouraged to be part of the conversations.

Often senior staff attended Rounds only if they were presenting on the panel. Such occurrences were considered a success [‘We asked the chief exec to be on the panel. I think that really boosted numbers’ (Willow-178-Clinical-Lead)], as when senior trust people are present staff feel that their concerns are being heard.

Participants suggested that the value of the intervention is undermined when senior staff do not attend Rounds, inadvertently giving staff licence to do the same:

If you show a commitment and you want to show to everyone that this is how important this is, that tells me volumes. If the chief exec[utive] is saying I’m so busy I can’t go there, that’s the message we are giving the people, if you are busy don’t go.

We did hear examples of senior managers supporting attendance by, for example, putting measures in place to encourage and enable ward-based staff to attend Rounds:

So what happens now is if it’s a nurse-related Round the matrons will make sure the nurses are attending because the ‘frequent flyers’ tend to be the corporate staff and people who have the times in their diaries to manoeuvre around and one particular Round [. . .] corporate teams [were] going to relieve the nurses for an hour so they could come.

Reasons for pausing Rounds

We noted the challenges of sustaining Rounds in many case studies, and how a number of factors contributed towards making Rounds unsustainable (see also Chapters 4 and 6). In the words of one case study facilitator (Ash), which was struggling to run Rounds, the core Rounds team faced a ‘perfect storm’ of simultaneous contextual factors, which contributed to the decision to temporarily pause Rounds. These included individual and interpersonal factors (facilitators and clinical leads taking on more roles and duties outside Rounds, reducing capacity; difficulties accessing clinical cases and panellists; loss of administrative support; and newly trained facilitators leaving); organisational and intrastructural factors (the need to cancel Rounds owing to NHS pressures such as junior doctors’ strike or a lack of beds); and changes to the e-mail system meaning that it was not possible to publicise Rounds via organisation-wide e-mails.

Similarly, another of our case studies (Horse-chestnut) attempted to restart Rounds, but this was unsuccessful because of a combination of factors.

• Individual factors: facilitator burden, turnover – loss of the passionate original facilitator who had established Rounds, another facilitator leaving post, facilitator burnout and associated disillusionment with Rounds.
• Interpersonal factors: facilitators and clinical leads in roles that limited their capacity and ability to find suitable stories and panellists.
• Organisational factors: reduced senior management support, increased workloads and pressures leading to less attenders/less diverse audiences, loss of suitable Rounds venue owing to resources being cut, difficulties of sustaining Rounds in two locations because of wide geographical location/scattered teams and a perception that the organisation had a ‘blame culture’, which led at least one attender to report an unwillingness to volunteer as a panellist.

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. (Figure not reproduced here; see the original article.)

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:

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.

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.

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.

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’.

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.

Audience characteristics

Size

The size of Rounds audiences varied considerably between and within sites (see Chapter 4). They varied from 150 (Cedar) and occasionally dropped to single figures, with sites reporting audiences of fewer than 10 (Ash, Horse-chestnut). Attitudes to a viable number also varied. Rounds were sometimes cancelled because panellists were not available; for example, in Elderberry the Round was cancelled 5 minutes after it had been due to start because the numbers were considered too low for it to be viable (n = 15). The facilitator explained that running the Round would have put too much pressure on audience members to contribute and that it would have been an uncomfortable experience for everyone involved. At other sites, however, we observed Rounds running with a number smaller than this, and working well for the audience and panellists (see Appendix 20).

Composition and diversity

A diverse audience was felt to be important for a number of reasons, most notably because it is associated with firing mechanisms on ‘contextualising patients and staff’ and ‘shining a spotlight on hidden stories and roles’ (see Chapter 8). Many sites found it hard to achieve audience diversity consistently, despite valiant attempts, with some staff groups (such as ward-based staff; see Chapters 4 and 6) being continually under-represented.

Having a visible senior management presence at Rounds was viewed by some participants as a ‘double-edged sword’. As outlined above, their presence was considered helpful in demonstrating the value the organisation placed on Rounds, and in some new case study sites chief executives/board directors were panellists at their early Rounds, which was well received by audience members. It provided powerful, memorable examples of ‘role modelling of vulnerability’, and opportunities for ‘shining a spotlight on hidden stories and roles’ (see Chapter 8). However, a few facilitators noted that there were benefits from having an intervention that was ‘under the radar’ and there were dangers in managers wanting to influence how Rounds were run. Rounds becoming ‘corporate’ needed to be firmly resisted, as this would be the antithesis of Rounds:

Why Rounds have value is they sit right at the section between the organisation and clinical work and that’s where the culture of change can happen because they’re not corporate even though they actually are because the organisation has to endorse them.

Others suggested that audience members also had to feel very ‘safe’ in Rounds to disclose challenging views on their organisation in front of senior board members.

Rounds characteristics

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

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

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

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

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).

Fidelity to the Schwartz Rounds model

Fidelity is the idea that intended results can accrue if there is adherence to well-evidenced and successfully developed intervention components. Put simply, fidelity means that Rounds are conducted as intended, in this case using the UK ‘Schwartz Rounds model’ taught in training, using the PoCF handbook and via mentors.

The Consolidated Framework for Implementation Research offers an overarching typology for implementation science,70 and suggests that interventions can be conceptualised as having ‘core components’ (the essential and indispensable elements of the intervention) and an ‘adaptable periphery’ (adaptable elements, structures and systems related to the intervention and the organisation into which it is being implemented). Rounds are a complex and multifaceted intervention, with many interacting components. Using the Damschroder et al.70 typology, we analysed our data to identify and determine the ‘core’ (Box 1) and ‘adaptable peripheral’ components (Box 2) of Rounds to make these visible (they were hitherto implicit and unidentified). We tested them with experienced mentors and key PoCF stakeholders in focus groups to check for comprehensiveness and agreement.

Leadership: senior clinician leadership.

Facilitation: facilitator led, neutral, group work, psychology and/or psychotherapeutic skills. Two facilitators/co-facilitation.

Regularity: series of events over time (i.e. not one-off events).

Integrity: Rounds not combined with other interventions or used for other organisational purposes.

Food: available for Rounds attenders.

Group setting: Rounds is a group intervention with group participation.

Participants: (panellists and audience) – staff only (no patients).

Audience discussion: stories to trigger reflection and sufficient time for audience discussion.

Trust, safety and containment: pre-Round safety checks, ground rules on confidentiality.

Pre-prepared staff stories: guidance on crafting story and identifying what will resonate with audience in panel preparation.

Focus on emotional impact on staff, the non-medical aspects of work: rather than clinical details, problem-solving, outcomes-oriented.

Diversity: open to all vs. targeted, multidisciplinary vs. unidisciplinary groups.

Duration: 1 hour vs. < 1 hour.

Panellists: minimum of two, maximum of four.

Staff stories: live vs. filmed stories.

Rounds format: (a) live vs. teleconferencing/videoconferencing, (b) panellists’ stories first vs. staff stories and audience discussion integrated.

Scale: single organisation vs. multiorganisation.

Regularity: more than vs. less than monthly.

Built environment: differing room layouts can be used [panellists at front (usual), some circular, some theatre style].

Focus of story: the style and structure of the stories – theme vs. case-based stories.

The principles of realist evaluation challenge the idea that context is always changing and that adaptability to context, as opposed to fidelity to implementation, holds the key to intervention success. It is possible that there are settings and cultures in which Rounds do not hold or produce intended positive outcomes when adherence to the core components is maintained. However, in the context of a high-income health-care setting, we have found that maintaining fidelity to core components, while being willing to tailor an intervention to particular local contexts if required (i.e. changing the adaptable periphery components), is consistent with a realist evaluation approach.

We report and discuss three of the core components in the following sections, as we have not presented data on these three elsewhere and all others have been summarised earlier in the report.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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).

Characteristics of ‘successful’ and ‘unsuccessful’ Rounds

During our analysis phase, two of the team (ER and ML) each identified a Round that they considered was ‘successful’ and ‘unsuccessful’ in each of their case study sites, and for which they had observation field-notes from a panel preparation meeting and from the Round itself. One example came from a new Rounds site and the other came from a more established Rounds site. From these observations, we compiled a joint list of characteristics of successful and unsuccessful panel preparation meetings and Rounds (see Report Supplementary Material 8).

Summary

In summary, we have identified multiple, interconnected contextual layers that affect and explain variation in Rounds implementation (see Chapter 8). In realist evaluation terminology, these contextual factors operate together to ‘fire’ or turn up a ‘dimmer switch’ underlying ‘mechanisms of action’, so they are perhaps best viewed as operating in bundles of factors. We have further identified core and periphery elements of fidelity to the Schwartz Rounds UK model. The case study Rounds we observed were run regularly and were not combined with other interventions, and food was always provided. Panellists and an audience were present, stories were pre-prepared and there was time (usually 30 minutes) for audience involvement and group discussion. All Rounds providers had a senior clinician as leader and usually the Rounds we observed had two facilitators. We have identified key differences between new and established rounds and have suggested that Rounds are a ‘slow burn’ intervention that have a cumulative effect over time, such as audience ‘Schwartz savviness’, audience trust and confidence, and facilitator confidence. These are explored in more detail in Chapter 8.