Introduction
This chapter discusses our findings in relation to the aims and objectives of the study, as outlined in the protocol and in Chapter 2. We examine our findings in the context of existing evidence, consider the strengths and limitations, and draw conclusions.
Overview of findings
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.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.
| Study phase | Key aims and objectives | Summary findings/outcomes |
|---|---|---|
| Phase 1: literature review | 1. Identify literature providing a definition of Rounds to identify key features of Rounds and create a composite definition 2. Identify and critically appraise all empirical evaluations of Rounds 3. Identify alternative interventions, describe their key features and scope their evidence base 4. Compare each intervention in relation to the core features of Rounds 5. Identify how Rounds might work by (a) exploring the theoretical literature on reflection, group work, disclosure and safe environment; and (b) speaking to the original architects of Rounds to determine the underlying ‘programme theory’ | Composite definition and key features identified to aid comparison Overall evidence base for Rounds is limited in terms of quality: few have controls/comparison groups and many use unvalidated measures Findings reported the value of Rounds to participants with self-reported positive impact on individuals, their relationships with colleagues and patients, and wider cultural changes Compared Rounds with 11 interventions: evidence was scant or of low or medium quality. Rounds offer unique features: organisation wide/all staff/disclosure optional Identified key mechanisms by which Rounds may work, including reflection, group work, disclosure and safe environment, and theories examining how these mechanisms may operate in Rounds Seven guiding principles identified for Rounds that contributed to initial programme theory |
| Phase 1: mapping study | 6. Map the profiles of current UK Rounds provider organisations to inform sampling of case study sites for maximum variation: reasons for (and time since) implementationattendance at Roundscost and resource implications to establish and sustain Rounds | Providers included NHS acute trusts (75%), hospices (22%) and others, and over half were based in the south of England Adoption reasons included need to focus on staff well-being; response to Francis report;3 PoCF dissemination activities; and availability of funding Challenges to implementation and sustainability included attendance (especially ward staff), and workload/resources required for running Rounds Staff time spent ranged from 1 to 82 hours per month (mean of 28 hours). Costs were mostly for staff time, which was widely variable: median cost £225 per Round. Food costs averaged £5 per head |
| Phase 2a: staff survey | 7. Evaluate whether or not regular Rounds attendance has an impact on health-care staff engagement and well-being, social support for staff and behavioural change towards patients and colleagues, compared with non-attenders 8. Investigate whether or not frequency of Rounds attendance was associated with greater improvements in health-care staff work engagement, well-being, social support for staff and behavioural change towards patients and colleagues 9. Determine factors associated with Rounds being perceived as useful, or barriers to attending Rounds | The primary hypothesis that work engagement would be positively associated with Rounds attendance was not supported In contrast to previous studies, we were able to demonstrate a clear association between Rounds attendance and psychological well-being We noted changes in the GHQ-12,82 which measures minor incidence of psychiatric morbidity, where among regular attenders of Rounds, the incidence dropped from 25% to 12%, compared with a drop from 37% to 34% among non-attenders Majority of respondents found Rounds useful, and the more useful attenders perceive Rounds to be, the higher their levels of psychological well-being after 8 months (compared with levels at baseline) Barriers to attending Rounds more regularly are practical: pressure of time or physically not being able to get to Rounds (schedules/locations/no one to cover/breaks too short) For non-attenders, a key barrier is knowing what Rounds are or believing that they need to be invited |
| Phase 2b: organisational case studies | 10. Examine staff experiences of attending, presenting at, facilitating and leading Rounds and reported outcomes 11. Examine how Rounds are operationalised and the mechanisms by which well-being and social support might be influenced (or not), including: reasons for variance in attendance and attendees experiencesinfluence of variance in facilitation (e.g. in relation to content/style)topics presented and Round climatesfactors influencing ‘success’ or otherwise of Rounds in organisationsany influence on team hierarchy/team work and on coping with stressany reported behaviour change towards patients and colleaguesincluding wider ‘ripple’ effects felt in day-to-day practice 12. Understand how Rounds ‘work’ in the UK, for whom and in what contexts; to suggest ways to improve their effectiveness; to inform decisions about their implementation in other contexts; and to understand what is causing variations in implementation or outcomes | Participants described Rounds as powerful, interesting, engaging and supportive; staff reported increased empathy and compassion for patients and colleagues and positive changes in practice In contrast to previous studies, our survey demonstrated a clear association between Rounds attendance and subsequent psychological well-being; attendance was associated with a statistically significant improvement in staff psychological well-being Rounds, when implemented as per model, provide opportunities for staff to feel safe enough to reveal themselves as human and vulnerable, which reduces shame, stress and anxiety, and improves coping, allowing staff to process difficult emotions and experiences, making themselves more emotionally open and available to patients and colleagues (and self), fostering empathy, resulting in greater compassion for patients and staff Nine CMOs identified with outcomes: trust, emotional safety and containment (enabling staff to be better practitioners, to reflect and change behaviour and to increase their empathy for patients) (and) group interaction (increased staff support, cohesiveness and better teamworking supporting improvements in patient care) were prerequisites for creating a countercultural space in Rounds (which shifts conversations in the organisation towards more openness, honesty and compassion for each other) where staff could tell stories (resulting in improved compassion and understanding for others and self, creating greater resilience through reflection) self-disclose their experiences to peers (greater trust and empathy for each other and improved connections and teamwork) role model vulnerability (inspires others to be honest and allows staff to see colleagues as human, breaking down barriers and creating a level playing field, which facilitates support and increases challenge and patient safety) provide important context for staff and patient behaviour (creating empathy and compassion for patients, family and staff and behaviours to be seen in context reducing stereotyping) hidden staff and patient stories reduced isolation and enhanced support/teamwork (reducing isolation, creating a cohesive community where staff offer and receive help, encourage and inspire each other, creating support) staff learned through reflection, resulting in ripple effects and outcomes |
| Overall analysis and cross-case analysis | 13. Establish contexts and mechanisms whereby Rounds influence staff well-being at work and social support 14. Identify and evaluate any changes (outcomes) that take place in relationships between staff who attend Rounds and their patients and colleagues 15. Identify and consider any wider changes that may be felt in teams or across the wider organisation regarding quality of patient care and staff experience and, if so, how these may be linked 16. Make recommendations regarding the role of Rounds in health-care provider staff support | We identified core (group intervention focusing on staff experience with good facilitation and the creation of a safe space facilitation) and peripheral (diversity, duration, scale, etc.) components which operate to ‘fire’ the underlying mechanisms and create outcomes (see above) Rounds were implemented variably. Challenges included attendance (particularly ward staff, those with less autonomy), and the workload and resources required to sustain them Rounds have a cumulative effect over time, with the intermediate outcomes of one Round (increased trust and empathy) becoming a resource for the next Round through, for example, a Schwartz-savvy audience who support the facilitator in ensuring safety and containment, building trust and a supportive community Reported outcomes included increased empathy and compassion for colleagues and patients, support for staff and reported changes in practice – including new support groups for staff; changes in protocol; and cultural changes including different organisational conversations |
Mixed-methods integration of findings
We have described in Chapter 2 the extent to which we have used mixed methods and integrated findings to incrementally build our understanding of how Rounds work. In relation to the qualitative and quantitative approaches in phase 2, there were some key similarities and differences in findings that warrant attention. Both data sets provided evidence that attendance/contributing to Rounds is associated with improved well-being. The qualitative data reported increases in empathy, compassion, peer support, reflection, work engagement and communication with patients (in addition to other outcomes not measured in the survey). However, although the survey reported small increases in all of these measures for regular attenders, none was statistically significant. We have explored the potential reasons for these differences (Table 28). Overall, we suggest that the complementary and contradictory findings of the qualitative and quantitative methods have provided richer insights and a more comprehensive evaluation of Rounds.
| Approaches to explore data disparities (Moffat et al.126) | Application to our evaluation [quantitative = survey; qualitative = case study (interviews/observations)] |
|---|---|
| Treating methods as fundamentally different | Quantitative and qualitative components had different (although related) research questions, and approaches to data collection/analyses are based on fundamentally different theoretical paradigms. While this may partially explain the disparities, the selection of survey measures was realist-informed (by our initial programme theory) |
| Exploring the methodological rigour of each component | Both quantitative and qualitative were conducted rigorously Quantitative: power calculation was based on whole sample of attenders vs. non-attenders across all 10 sites (thereby not sufficient for individual case analysis) Qualitative: our interview sample was diverse, large and included non-attenders. We actively sought disconfirming cases |
| Exploring data set comparability | Quantitative: most sites (and all participants) were new attenders at baseline and remained relatively ‘new’ even if classified as regular attenders Qualitative: most sites were established Rounds sites (and participants were mostly experienced Rounds attenders and/or panellists) We cannot know the GHQ-12 status of our qualitative sample |
| Collection of additional data and making further comparisons | The research timetable (survey completed October 2016) did not allow for analysis to inform further data collection in the qualitative component |
| Exploring whether or not the intervention under study worked as expected | Quantitative: each ‘dose’ of a Round is treated as identical. Few regular attenders came from established Rounds sites Qualitative: Rounds type and intensity varied within and between case study sites (impacts on mechanisms and outcomes). In addition, fidelity across sites was variable |
| Exploring whether or not the outcomes of the quantitative and qualitative components match | Quantitative: most of the survey measures were not validated for this population; survey measures were selected at the study start, before the complexity of Rounds was fully appreciated. All measures did move in expected direction, although not statistically significant Qualitative: some findings were not captured in survey (e.g. vulnerability, contextualisation of patients and staff); the complexity of participants’ accounts (e.g. emotion in reflection) were not encapsulated in the measures |
Strengths and limitations of the study
This was a very challenging intervention to evaluate and we note the complexity of the study, in particular (as outlined above) the challenges of synthesising the methods and the diverse findings. One of the main strengths of our study is the use of mixed methods and their integration to support a more comprehensive interpretation of our findings. Our study focused only on staff experiences. We initially considered including the impact of Rounds on patient experience, given that Rounds are predicted to have an impact on patient care. However, the difficulties of attribution of effects of Rounds on patients, given the complexity of health-care provision (confounders), meant that this was not possible. Furthermore, substantial evidence now links staff well-being with patient experiences of care,68,76,77 justifying the focus on staff well-being. Other strengths and limitations are detailed below.
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.
Recommendations for future research
This study has identified the need for research in the following areas.
- Evaluation of Rounds implementation: (1) in new settings (e.g. primary care, prisons, medical schools), (2) to extend reach (e.g. ward-based staff) and (3) adaptations (e.g. filmed stories).
- Storytelling: telling stories as a way of sharing personal experiences is increasingly being used in the field of mental health, well-being and recovery. The potential benefits for health-care staff in gathering and sharing stories in other formats, settings and audiences should be explored and evaluated.
- Development of outcome measures that are fit for purpose (e.g. compassion, quality of communication with patients, staff empathy as experienced by patients and staff).
- Evaluating the impact of Rounds on organisational culture, although, given the challenges we experienced observing ripple effects, this is difficult.
- Rounds legacy, spread and sustainability over time, and where and how adopted and adapted, for example in settings outside acute care – nursing homes, ambulance staff and primary care – and also possibly outside health care – police, teaching, armed forces.
- Methodologically: our experience highlights the importance of using mixed-methods designs for evaluating such complex interventions, which, together with the use of realist evaluation, provides much greater insights – moving the analysis beyond description – and allowing the team to draw on a wide range of theories to support understanding of the mechanisms at play.
Implications for policy and practice (objective 16)
Our study suggests that there are some core components [senior clinician leadership; two facilitators with group work skills; that Rounds are not one-off events but a series; that they are not combined with other interventions (integrity); that food is available; that a Round is a group intervention with group participation; that Rounds are staff-only events (not patients); that stories are told to trigger audience discussion; that trust safety and containment is maintained; that staff stories are pre-prepared; and that Rounds focus on the emotional impact of work on staff, rather than on problem-solving or clinical detail]. These components and others are expanded on to provide more detailed recommendations for policy and practice in our accompanying organisation guide86 to implementing and sustaining Rounds.
Higher-level implications for policy and practice that arise from this study are as follows.
- Our data suggest that Rounds support staff and improve staff psychological well-being, enabling them to provide better patient care. Rounds may help organisations meet the National Institute for Health and Care Excellence (NICE) guidance129,134 and the Commissioning for Quality and Innovation (CQUIN)135 framework for ensuring well-being of staff. They may also support organisations to improve quality of care and change organisational culture. Rounds were not suitable for or accessible by everyone, and should be offered in addition to other forms of psychological support for staff, such as clinical supervision, and not instead of these interventions. Organisations yet to implement Rounds may want to consider this evidence when making their decisions.
- Organisations may want to consider implementing Rounds alongside other interventions as part of their quality improvement and staff support strategies because our evidence has highlighted the unique resources offered by Rounds – in particular that they are open to all in the organisation.
- Our findings suggest that the countercultural space that Rounds provide is an important aspect of organisational culture change, and may help organisations meet recommendations arising from the Francis inquiry.3
- Our findings suggest that it is important to ensure board clarity about the ‘slow’ nature of the intervention, the difference of the space and the ways in which the Round is likely to have an impact on staff experience and organisational culture over time. Furthermore, the felt need to demonstrate outcomes by facilitators (and some board members) in our study – in line with the prevailing health-care culture – is in stark contrast to this counterculture space, and should be treated with caution.
- Although Rounds are intended to be open to all, in practice we found that this was not the case. Senior management support is needed to put in place initiatives that enable all staff groups to attend.
- The evidence in this report suggests that there are challenges to the sustainability of Rounds, and organisations may want to consider how Rounds are resourced given the time and workload required. Organisational support, particularly in the form of administrative support, is needed to sustain Rounds.
- Our findings revealed that running Rounds places considerable strain and burden on facilitators, and suggests that the long-term sustainability of Rounds depends on shared ownership of Rounds. Organisations (rather than the facilitators) might consider taking responsibility for ensuring sustainable success.
- In terms of sustainability, our findings suggest that steering group members attend Rounds regularly and refresh/renew their membership on a rolling basis, for example 6 to 12 months. This is anticipated to reduce the burden on individual members and better support facilitators and clinical leads by finding stories and panellists, reviewing what worked and what could be improved and, when necessary, help support facilitators to maintain and improve psychological safety in Rounds.
Full details of our implications and recommendations for policy and practice can be found in our Organisational Guide to Implementation.86
How has this study contributed to strengthening the evidence base on Schwartz Rounds?
Previous evaluations of Rounds have been limited quantitatively by their use of non-validated outcome measures, and lack of control group comparisons (see Chapter 3). Our evaluation addressed these limitations by using the most robust validated measures of outcomes available, and by including a non-attender control group in the survey. Furthermore, previous evaluations had focused solely on the impact of Rounds on attenders, whereas the realist-informed evaluation we undertook examined how, why and for whom Rounds had an impact. This required determining an initial programme theory about how we felt Rounds worked, based on evidence and theory, which we then used to explicitly underpin our mixed-methods evaluation. The causal explanations and evidence-informed programme theory provide a rich, in-depth explanation about how Rounds work, for whom and why, providing an important framework for future evaluations of Rounds, and their implementation.
Conclusions
This is the first longitudinal realist-informed mixed-methods, large scale evaluation of Schwartz Center Rounds® in the UK. Rounds have been shown to offer unique support compared with other interventions, and attending Rounds is associated with improved staff psychological well-being. Providing high-quality health care has an emotional impact on staff. They experience high levels of psychological distress, face increasing levels of scrutiny, regulation and demand, and have increasingly limited resources. Within this context, Rounds offer a safe, reflective space for staff to share stories with their peers about their work and its impact on them. Staff report increased empathy and compassion for patients and colleagues and report positive changes in practice as a result of attending Rounds. Some staff reported that attendance was an issue for some groups (especially ward-based staff) and that organisational support is needed to sustain the initiative. It is feasible for Rounds to be implemented across a range of health-care organisations, and, although costs varied, these should be considered acceptable for achieving such outcomes for staff and patients.