Mapping Schwartz Rounds

Introduction

The aims and objectives of the mapping element of phase 1 were to map the profiles of current UK Rounds providers including the reasons for (and time since) implementation, how organisations had implemented Rounds, and attendance at Rounds; and to determine the cost and resource implications required to establish and sustain Rounds (objective 6). These profiles also informed sampling of phase 2 case study sites for maximum variation.

This chapter includes reference to findings reported in Robert et al.1 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/.

Methods

Overall design

A mixed-methods approach comprising:

1. the collation and analysis of secondary data to map and profile Rounds providers
2. an online cross-sectional survey and telephone interviews completed by the clinical lead or facilitator in Rounds providers.

Sampling frames and samples

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

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

Data collection access

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

FIGURE 3 Recruitment and data completion for survey and interviews. (Figure not reproduced here; see the original article.)

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

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

Data collection

Secondary data

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

Online survey

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

Telephone interviews

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

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

Pilot testing

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

Data analysis

Secondary data

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

Survey

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

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

Interviews

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

Results

How many and what types of organisations were running Rounds?

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

FIGURE 4 Location of Schwartz Rounds sites in England (n = 154) up to the end of 2016. © OpenStreetMap contributors. These data are made available under the Open Database Licence http://opendatacommons.org/licenses/odbl/1.0/. Any rights in individual contents of the database are licensed under the Database Contents License: http://opendatacommons.org/licenses/dbcl/1.0/. (Figure not reproduced here; see the original article.)

Types of organisations

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

Year of implementation

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

FIGURE 5 Implementation of Rounds: number of new providers running their first Round per year (to December 2016; n = 154). Figure excludes providers outside England (n = 10) and ‘other’ providers (n = 5) including an ambulance trust, three medical schools and a private hospital. LD, learning disability. (Figure not reproduced here; see the original article.)

Why were Rounds implemented?

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

How did staff first hear about Rounds?

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

Are Rounds adopters different from non-adopters, or earlier adopters different from later adopters?

Adopters were not significantly different from non-adopters in relation to the NHS Patient Survey scores or CQC risk bandings, but adopters had higher scores on NHS Staff Survey ‘engagement’ in 2013 (Tables 7 and 8, and see Robert et al.1).

In relation to the timing of adoption, analyses of data for the 3 years before adoption according to whether adopters were early or later adopters resulted in two weak positive correlations: earlier adopters had better NHS patient experience results in 2013 and 2015 (r = 0.25, p = 0.02, and r = 0.24, p = 0.03, respectively). Additionally, providers that adopted Rounds earlier (i.e. innovators and early adopters) tended to have better NHS staff and NHS patient survey results than non-adopting providers or providers that adopted later (late majority, laggards). However, we found little evidence in our interviews that the adoption of Rounds was driven by such performance indicators.1

Reasons for adopting Rounds

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

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

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

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

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

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

How are Rounds being implemented?

Preparation for implementing Rounds

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

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

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

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

Organisational structure for Rounds

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

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

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

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

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

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

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

The frequency, timing and scheduling of Rounds

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

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

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

Publicising Rounds

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

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

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

Attendance at Rounds

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

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

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

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

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

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

Measuring/evaluating the impact of Rounds

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

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

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

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

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

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

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

Challenges in running/sustaining Rounds

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

What were the resource implications of running Rounds in organisations?

Non-staff costs

Fees to the Point of Care Foundation

The cost of the licence to implement Rounds, including 2 years of operational support (comprising facilitator training, mentorship, webinars and web resources access) and two places at its annual conference for Schwartz Community members, is £15,960 for NHS trusts (in 2009 this was £2500). Hospices and similar small providers are provided with the support in group cohorts at a cost of £4500 for 2 years.

After the first 2 years, providers can enter into ‘membership’, which renews the licence (enabling Rounds to continue) and provides ongoing support. The current 2-year membership rate is £3780 for large organisations and £1680 for small organisations. (All figures include value-added tax and were correct on 13 February 2017.)

Various providers have benefited from subsidised rates, with grants variously from the Department of Health and Social Care, LETBs and Macmillan (see Figure 1).

Other non-staff costs

• Eight organisations reported having one-off costs associated with a launch event, ranging from £35 to £1500.
• Most (34/42) organisations were not charged any room hire fee. Four (three NHS trusts and one hospice) paid a fee of between £100 and £310 for each Round.
• Most organisations (30/42) either minimised printing/advertising costs by only using online forms of communication, or stated that such costs were met by provider communications teams and not charged directly to Rounds. Seven organisations incurred small sums (£10–25) for printing or other costs associated with promoting Rounds. One organisation had purchased a public address system for Rounds at £400.
• All provided catering (although two stated that this was provided ‘in house’ and could not provide costs). Most frequently this was a sandwich buffet (57%). Cost varied from £10 to £700 a Round, with a median of £225 (Table 11). The average cost for a sandwich buffet was around £5 per head.

Staff costs

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

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

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

Chapter summary

There has been a rapid uptake of Rounds in the UK, particularly during 2013–15, although uptake has been variable across different types of organisations and geographically – and now appears to be slowing. Although the peak of uptake coincided with the publication of the Francis report in 2013,3 we found little evidence of a direct causal relationship, although it may have been a catalyst. Explanations for adoption were most likely to concern a felt need to provide staff support/well-being, perhaps in recognition of the established link between staff well-being and patient experience.68,76,77 Earlier adopters appear to have been influenced by a combination of factors, including that Rounds have many favourable attributes to support uptake, together with the active dissemination by organisations such as the PoCF, and the felt need to be addressing staff well-being. More recent adopters have also been influenced by the provision of funding to support Rounds. We found little evidence of performance driving adoption, although there were several weak correlations: adopting providers had higher levels of staff engagement (compared with non-adopters) and earlier adopters had better staff and patient survey results than later adopters and non-adopters.

There is wide variability in relation to how Rounds have been implemented. Challenges to implementing and sustaining Rounds include issues regarding attendance (particularly widening accessibility to groups of staff tied to wards, those with less autonomy), and the workload and resources required for planning and running Rounds. The resources for running Rounds are highly variable – both staff and non-staff costs – across and within types of providers. The majority of time spent on Rounds activities was non-contracted/job planned, and often a considerable number of hours per month.