Staff experiences of Rounds

Overview

This chapter provides an overview of findings from the case studies in relation to staff experiences of Rounds.

Objectives

The objectives are to identify:

• staff experiences of attending, presenting at, facilitating and leading Rounds and reported Rounds outcomes (objective 10)
• reasons for variance in attendance, including enablers of and barriers to attendance (objective 11a)
• reasons for variation in facilitation (objective 11b).

Methods

Data are drawn from our nine case studies (Tables 22 and 23) and phase 1 mapping interviews (Table 24). Further details of methods and analysis are given in Chapters 2 and 4.

Case study participants were identified through purposive and snowball sampling. Participants who agreed to be contacted were sent a participant information sheet (see Appendix 17) and invited to take part in a 30- to 60-minute interview. These took place by telephone or in person between April 2015 and June 2016, at which time the interviewer explained the objectives of the study, answered questions and took informed written consent (see Appendix 18). The semistructured interview schedule (see Appendix 19) was developed to explore participants’ experiences of facilitating, leading, supporting, and attending and/or not attending Rounds. Each interview was transcribed by a professional transcription service and analysed using a thematic analysis approach, following key stages of data familiarisation, data reduction and interpretation. A two-stage thematic analysis process was conducted using (1) an inductive analysis of a sample of transcripts to generate initial codes and themes that fed into the development of (2) an a priori coding scheme, informed by the findings from the literature review (see Chapter 3) and early observations of Rounds. The themes were examined across participants for consistency and, when appropriate, constructs were categorised into smaller units. All data were coded in the qualitative data analysis software package NVivo (QSR International, Warrington, UK).

Results

Attendees’ experiences

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

Reasons for attendance: enablers

Word of mouth was effective in encouraging people to attend Rounds:

I do try to encourage a number of my colleagues to go [. . .] I sometimes think when you see it [the round publicity] [. . .] I didn’t have a clue what that was about [. . .] and I passed it by for a bit. So a bit more explanation under it [the publicity] that you can easily see might capture people’s attention [so they might be persuaded] to go.

When a topic seemed relevant and resonated with potential audience members, they were more likely to go:

I went to the [name of hospital] one because the topic was relevant to me, which was ‘the hospital at night’. And I wanted to go because I often am here by myself working [. . .] it’s a very intimidating place to be at night for me by myself.

The publicity for and titles of Rounds were important influences on whether or not staff attended:

I just saw a poster in the ward, and actually I was saying to someone ‘I can understand why patients feel angry’ and then I said, ‘Oh, maybe I should go to this’.

In other examples, a lack of knowledge about Rounds meant that the publicity did not initially engage:

I used to see the Schwartz Round advertised and [. . .] delete the e-mail because it didn’t make sense. The title didn’t really mean very much to me. I get lots of e-mails. Then one day I read it a bit more and I thought ‘oh that sounds really interesting’.

For many staff, it was not enough to be told about Rounds, or to see publicity, to really understand what Rounds were: they needed to experience them.

Finally, non-clinicians told us that they thought that Rounds were a helpful way of finding out about the experience of clinicians and, as a consequence, they felt more connected to the organisation’s purpose of delivering excellent patient care. Some participants told us that they found witnessing colleagues’ distress in Rounds uncomfortable and that it felt voyeuristic.

Reasons for attendance: barriers

Reasons given for not attending included not understanding what Rounds were and practical difficulties such as location and timing.

A few Rounds attenders whom we spoke to decided that Rounds were not for them, and Rounds attendance was an issue for some staff. Certain groups were more likely to attend than others. Ward-based staff in acute care and community staff, who faced geographical challenges accessing Rounds, struggled to attend Rounds, despite initiatives to address the barriers. Ward nurses, on 12-hour shifts with only two half-hour breaks, lacked the autonomy to make the decision to attend or found it hard to find the time to attend, particularly at lunchtime when patients needed support with meals, unless someone else covered the ward or it was particularly quiet. Even those with autonomy over their work schedule experienced some difficulty, with work pressures being the biggest obstacle to attendance. Some organisations experimented with running Rounds at different times of the day to attract different staff groups. Other strategies included releasing staff to attend Rounds on a rotational basis and prioritising attendance among those who had a personal connection with the case being discussed:

It tends to be quite a lot of senior people that go [. . .] What’s up with one person feeding back at that senior level and getting the girls on the ward [to attend], giving them a little break to go to the Schwartz Round because it’s beneficial for them? It’s good for the health-care assistants, it’s good for the ward clerk, everybody makes a team [. . .] One senior member go, feedback, take it in turn every Schwartz Round, utilise that time to go and cover your member of staff on the ward to free them up, make them feel valued and let them go to the Schwartz Round and hear how good it is.

Staff perceptions of Rounds

Several interviewees were surprised by the extent of audience discussion and involvement, expecting the time to be occupied by formal presentations, or were surprised by their own emotional reaction and that of others.

In terms of Rounds’ structure, many appreciated the ritual and predictability, suggesting that this contributed to feeling safe; audience members valued hearing about the origins and history of Rounds, feeling that this contributed to Rounds’ legitimacy. It was recognised that Rounds needed time to evolve within organisations, especially as audience members became more accustomed to Rounds and the associated behaviours and etiquette.

Participants described Rounds as interesting, engaging and a source of support. Participants valued the opportunity to reflect and process work challenges. Many appreciated the opportunity to learn more about their colleagues, understand their perspectives and motivations, and engage in multidisciplinary interaction. This led to greater understanding, empathy and tolerance towards colleagues and patients. Key themes included:

• contextualising patients and staff
• seeing the person in the professional
• feeling that their experiences are validated and they are not alone
• levelling effect of Rounds
• acknowledging vulnerability (see Chapter 8).

These findings link closely to Chapter 8; thus, here we briefly present these themes, with further data provided in Chapter 8.

Rounds stories provided greater context regarding patients and staff, and attendees described gaining insight into the daily reality of other staff, which helped them recognise that they were united in common efforts to deliver health care. Attendees voiced greater respect and appreciation for colleagues after learning more about their role and had a better understanding of patients’, carers’ and staff’s behaviour, as well as the uncertainty involved in health-care work:

I think it certainly has enabled me to put myself a little bit more in the situation of my patients and think ‘actually what are they going through?’ It enables you to stop and draw on the experience [. . .] and that’s where I think it makes you better because you perhaps get less angry at people’s responses to things and realise that actually there is a lot of emotion involved within these situations and that they’re not just robots that are dealing with a case and it’s never black and white, I think you realise more and more as you listen to these Schwartz Rounds, there’s never a true right or wrong.

Rounds stories allowed staff to see the person in the professional, and corrected misconceptions that they held about individuals, helping staff understand each other’s behaviour, promoting tolerance and greater empathy in times of adversity:

I think it helps me understand other people’s perspectives. [. . .] If I can understand people that means I can feel more empathetic. [. . .] I like to think there’s a lot of understanding and empathy being created within the audience, [which] I hope is undoing some negative psychological processes as well as creating some important ones.

The majority described how Rounds validated their actions and emotions, helping reduce feelings of isolation. Rounds had a levelling effect by highlighting the reality that all staff groups, regardless of seniority and experience, encountered difficulties:

I find it of huge benefit to know that we are all in this together, that we do not have our heads down in the dust and the dirt pretending everything is all right. That it is OK to speak and say it is a really shocking environment that we work in and that we are all pushed to our limits on many occasions, affecting all aspects of our work. It makes us feel very uncomfortable because you want to give good care [. . .] and also [. . .] the target-driven nature of things [. . .] that human interaction with the patients [and] relatives has a tendency to go. [. . .] I just find [. . .] every meeting is enriching and a nourishment to one’s soul and psyche that [. . .] we can talk about it.

Rounds attenders were impressed by their colleagues’ honesty, especially those who showed vulnerability. Many felt that this was countercultural to the NHS mentality of appearing resilient at all times and was all the more notable when recognised in a public forum. Hearing senior colleagues express vulnerability, emotion and regret was said to be powerful and connecting and to provide role models. Such knowledge supported participants in the realisation that no one is infallible, acquitting many of unrealistic expectations. Awareness that all staff encounter difficulties in the emotional, social and ethical aspects of their work contributed to feelings of relief. Interviewees told how Rounds had been educational in helping them understand situations more fully and not as ‘black and white’, and promoting coping strategies to help them manage difficult situations.

Factors influencing whether or not audience members speak at Rounds

Audience members spoke when they had experienced a similar situation, when they felt that panel members would benefit from their contribution, when they wanted to provide moral support, and when they wanted their story ‘heard’. Some contributed only when they had sufficient authority on the topic and deliberately held back to allow colleagues an opportunity:

I’m not a person who says a lot, but I’ve probably [spoken] once [or] twice [if] there’s a topic or an area [that] I have an opinion or an experience [in and] that I feel is probably good to share with the audience.

Others spoke in support of colleagues on the panel or the facilitator to keep the Round safe; some were reluctant to show emotions publicly, and the presence of a line manager prevented some contributing. Other reasons why audience members did not speak in Rounds included a lack of confidence, not having a connection with the case, and a reluctance to engage with a contentious topic.

Round attendance outcomes

Individual-level outcomes

Individuals reported positive outcomes, for example increased reflection, self-efficacy, well-being, understanding of their own and others’ emotions, and a connection to others and to the organisation and its values. The free lunch made people feel cared for by the organisation. Rounds provided psychological relief through the open expression of strong emotions for those who shared their story:

It gives them that outlet [. . .] the gentleman that was upset about how that patient was treated a couple of days ago, it was still fresh in his mind you could clearly see he was quite distressed by what had happened and it was just allowing him just to talk about what had happened to other people [. . .] to get it off his chest and hopefully he will settle a little bit more after that.

Rounds helped remind staff to pay attention to their own well-being:

I’ve seen colleagues go off sick and [. . .] I think this is a reminder that we need to pay attention to those things. And although we help clients embrace change and cope with change, we need to make sure that we can do that with ourselves.

Group-level outcomes

Group-level outcomes included greater knowledge of colleagues’ roles and challenges; creating new connections between staff groups; better teamwork; improved communication; and feelings of greater compassion, empathy, cohesion and trust between colleagues:

What you can actually see is that cohesive team spirit being built [. . .] if you realise that other people are going through similar things. Or other people are going through things that you never even realised and they’re prepared to tell you and share that with you, it definitely builds up a level of trust which makes the team work better.

Rounds were reported by one facilitator to ‘change the nature of conversations’, and participants identified ways in which they had altered relationships between colleagues, including an increase in emotionally focused discussions and communication, resulting in less superficial dialogue between colleagues outside Rounds.

Patient-level outcomes

Rounds attendance contributed to patient care by allowing attenders to understand the wider context of patients’ and their families’ attitudes and/or behaviour, resulting in greater empathy and compassion towards them. This was especially important when staff had encountered hostile, aggressive, difficult or challenging individuals and situations. Some thought that Rounds had reminded them to see patients as people, helping them keep in touch with their own humanity while caring:

Under pressure to just keep doing more and more, it’s very easy to forget that your patients are people and just see them as tasks to be completed as quickly as possible. So I think a real reminder of the importance of a human element to care for the patients is huge and also a reminder to keep in touch with your own humanity as a health professional is important for [. . .] Self-preservation in this kind of environment.

Non-clinical staff and/or staff with limited patient contact told how Rounds provided them with a reminder of the clients they serve (the public):

I went because I sit in my office and a lot of times you forget that it’s actually patients you’re [helping]. I could be in a factory. It was nice for me to remember that when I’m doing my contracts and saying yes or no to a trial based on money.

Neutral or negative outcomes

Despite looking long and hard, we found very few participants who spoke negatively about Rounds, but those who did questioned the purpose of unearthing feelings of sadness, anger and frustration, and said that they found witnessing the agony of others uncomfortable:

If I switch my cynical head on it almost felt a bit like Alcoholics Anonymous[^®] [. . .] I’m not sure about the format where you kind of make four people share an experience as a catalyst to try to get the audience to participate, I thought that was a bit harrowing really.

The story was about how a professional who got involved with a patient, in the broadest sense and [the panellist’s] reflection was on how he dealt with that and so on. I did think that he [the panellist] was basically spying on other people’s agony somewhat.

Some participants found it hard to isolate the impact of attending Rounds, saying that Rounds did not single-handedly trigger change but were part of a diverse body of experiences that, collectively, had an impact on behaviour:

No [nothing had changed] not as a result of that [Rounds] directly. I think it’s very tough to assign changes in practice to one particular set of conditions, all these things get internalised don’t they?

I don’t think single-handedly they’ve changed anything for me, but they have reinforced other learning or teaching I’ve had from other sources. [. . .] They have confirmed aspects of what I now see I do as good practice, which is encouraging.

Interviewees were asked if they had been to any Rounds that they felt were ‘unsuccessful’ and to explain what it was about the Round that contributed to that. Attendees suggested that poor attendance, prolonged silences, strained discussions and perhaps a lack of personal interest in the Round topic defined whether or not they felt that the Round was successful:

I think there has been a couple [. . .] I don’t know if they didn’t work, but weren’t as well attended, lots of silences and it was quite difficult to get the discussion going. I don’t know whether [that’s because it] has to touch you personally or whether you have to have some investment in the topic.

Others, however, identified the importance of silence as a unique aspect of Rounds that supported contemplation, and provided a counterweight to their usual busy, noisy professional lives (see Chapter 8, Countercultural/third space for staff).

Panellists’ experiences

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

Motivations for presenting

Reasons given for agreeing to be panellists included professional development, increasing visibility and their own or team’s profile, seeking closure on a difficult situation, showing appreciation towards colleagues, sharing knowledge and helping others learn from their experiences. Panellists reported wanting to process a difficult clinical experience and said that they felt a sense of achievement after receiving positive audience feedback. Some respondents valued the opportunity to say thank you to colleagues publicly. In established Rounds sites, audience members were more likely to volunteer to be a panellist or suggest that their team might be willing, and learnt what makes a good Schwartz Round case or topic: ‘often people say “oh this is definitely going to be a Schwartz Round” ’ (Cedar-28-Panellist).

Panellists also described utilising Rounds to share experiences to enable learning, especially when the topic was associated with a misunderstanding or a lack of action:

I wanted to share that experience because I know that mental illness is quite stigmatised still in medical profession especially with colleagues in sort of A&E [accident and emergency] departments [. . .] I thought it would be a good opportunity to put it out there that if you’re frustrated, angry, scared and confused with our patients, we feel it as well sometimes.

Panellists’ experiences of Rounds’ stages

Panellists described their experiences of Rounds’ stages: ‘sourcing stories and panellists’, ‘panel preparation’ and ‘telling stories to trigger reflection and resonance in Rounds’ (Figure 6; see Report Supplementary Material 7 for a summary of these stages).

FIGURE 6 Stages of Rounds. (Figure not reproduced here; see the original article.)

Experiences of panel preparation

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

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

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

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

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

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

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

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

Pre-Round expectations

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

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

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

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

Experience of presenting

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

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

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

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

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

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

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

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

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

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

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

Facilitators’ and clinical leads’ experiences

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

Overall experiences

Facilitators perceived Rounds facilitation as a great responsibility, wanting to ‘get it right’ and feeling quite daunted by the whole experience. Facilitators were keen to make it safe for staff to share experiences, and to gain the audience’s acceptance and participation while maintaining control. Facilitators spoke of the courage needed to stand at the front of the room and ‘carry the Round’: ‘initially it’s completely scary in case you put your foot in it and fall flat on your face’ (Ash-400-Facilitator).

There were also some apprehensions that the Round discussion might not ‘work’ or be appreciated by staff, especially when Rounds were new to an organisation:

I was hoping it went well. It felt good. The evaluations were positive. I was just nervous because I was prepared as much as I could be and then realised as soon as we got to the audience bit I had no control.

Over time, many concerns decreased as facilitators’ confidence and experience increased.

Some held the joint role of clinical lead and facilitator. Key responsibilities of the clinical lead included spreading the word about Rounds and supporting the facilitator and steering group in finding and developing stories, and encouraging their medical colleagues to attend, as identified in the PoCF handbook. Clinical lead involvement varied across sites (see Chapter 7).

A lack of capacity to offer support before the Round, owing to other work commitments, was a challenge that the majority of clinical leads acknowledged and that meant that they could not support or release the facilitator from the Rounds’ associated task of panel preparation. Another downside of having missed panel preparation was the potential for clinical leads to be emotionally affected by the panellists’ stories during the Round:

I have to say [the facilitator] does all the [laborious work], all the preparation. I have tried to be present to prepare a few of the panel members, but it’s only been a handful and fortunately they appreciate how busy I am and they just prepare the panels and I just pitch up often. Which sometimes means that I haven’t heard the panel stories before and I get a bit hijacked by the emotions sometimes, because I’m hearing the stories fresh for the first time.

As with other key Rounds roles, clinical leads described giving over and above the formal resource allocation for Rounds. Despite their efforts, this still limited the amount of support they could offer, which contributed to feelings of guilt and/or a lack of preparedness for some. Clinical leads highlighted the impact that Rounds involvement had had on their practice:

It’s always a bit of time pressure fitting in the panel work and fitting in the Schwartz Rounds. There have been times where I’ve had to delay the start of my clinic because I’ve got a Schwartz Round steering group. But then that’s outweighed by the positive benefits of learning so much from attending the Schwartz Rounds and reflecting on your own practice and resonating with the case. So I think the positives outweigh the negatives.

I don’t have the opportunity to particularly clear my desk, clear my morning either before or after the Round [. . .] One day I went from the Schwartz Round straight into my performance meeting [. . .] And it’s really interesting in my head to compare the hour or so in the Schwartz Round which is a very compassionate, kind, listening environment to the very aggressive, unforgiving environment of my performance meeting.

(See Chapter 8, Countercultural/third space for staff for more about contrasting culture.)

Motivation and rewards

Facilitators and clinical leads were often important champions, motivating others to be involved and helping bring Rounds to their organisation. They were highly motivated and had a strong belief in Rounds and their importance in supporting staff in the difficulties they faced in their work. Facilitators described their personal reasons for being involved. These included a perceived alignment between the objectives of Rounds and the facilitator’s values, such as a professional interest in employee engagement and/or reflective practice. Interviewees reported that facilitating Rounds was a privilege, a pleasure and enjoyable, and gave them satisfaction:

As a facilitator, you have that wonderful, very privileged position of seeing both audience and panel, you can see everybody, and it’s just watching people’s reactions as they listen to stories, as they pluck up the courage to put their hand up and participate. It’s quite nice for you to see it flourish.

Facilitators found it rewarding when staff engaged in the discussion. Some considered this an indication of success:

It gives me a buzz when you see that people have really engaged with an issue and that it had some kind of impact on them, whether that’s about them feeling much better supported or perhaps it’s about them feeling better equipped to deal with a similar situation.

Being a facilitator was described as a challenging, rewarding and career-enhancing experience that brought new skills and confidence, which was good for personal and professional development:

I think it’s been a fantastic experience for me. I hadn’t done anything like this before [. . .] I’ve got more confident in helping facilitate Rounds. Initially, I remember feeling absolutely petrified, thinking how are we going to keep going. I still do that to a certain extent because I’m not in my comfort zone, so actually I think doing something out of your comfort zone is actually incredibly rewarding, especially when people are positive about it.

Facilitators felt that Rounds had caused them to reconsider the wider implications of their actions and behaviours, especially when interacting with patients and relatives:

I think they [Rounds] make me more reflective as a clinical practitioner. So I’m much more tuned in to how the patient might be feeling, how their family might be feeling and [so I] don’t concentrate so much on the medicine but think about the bigger picture and probably practise more holistically.

Facilitators also described how their involvement had made them more visible and created new connections:

You’re no longer invisible and it has been absolutely lovely forming connections with people who I’d have never got to meet otherwise and hearing about their work and hearing what they do and that has been wonderful.

Challenges

The challenges associated with facilitating Rounds included emotional and psychological concerns, a lack of time and support for Rounds, and pressure to make Rounds a success. For example, facilitators described concerns about keeping Rounds safe and their dilemmas about when and how far to intervene. Some deliberately held back in their facilitation, feeling that they did not always have the permission to step in, as Rounds, although having therapeutic benefits, were not a therapeutic intervention. Addressing the important issues while not taking the discussion ‘too far’ was a challenge. For example, a lack of expertise or experience concerning the content of the Round discussion was a factor that might prevent some facilitators from intervening when needed, yet a reluctance to engage in deeper emotional discussions regarding issues that happen in the workplace might prevent Rounds reaching their full potential:

If something was presented as a risk or issues of malpractice that would worry me because that’s where my clinical expertise is lacking and so I wouldn’t feel comfortable facilitating because I don’t deal with those situations routinely.

Facilitators were very mindful of not wanting to push panellists too far and cause distress, and they were alert to providing emotional safety and containment (see Chapter 8).

Lack of time and support for Rounds

A key challenge was having the motivation and resources to sustain Rounds. Many felt that the resources to deliver Rounds successfully were insufficient and diminished over time (e.g. steering group support) or had been underestimated. Many reported that there had been a surge of support for Rounds when first launched, which diminished with time. In some organisations facilitators were left to manage much of the planning and delivery, as those charged with the task of supporting Rounds (non-facilitating clinical leads, steering group members and Rounds administrators) became preoccupied by other priorities. Facilitators described how a lack of support made delivering Rounds difficult:

Preparing for them [Rounds] probably takes up much more time than I anticipated and particularly because the other co-facilitator is part time, so I often feel I’m doing a lot of the preparation – identifying and preparing panel members and organising steering groups.

Some facilitators were left to manage the weight of responsibility owing to their perceived expertise. However, there was widespread agreement that the responsibility of Rounds should not rest with one or two individuals given the enormity of the task and the issue of sustainability:

It’s important [Rounds are] not just for two people to run, especially given how huge it is and how difficult engaging people [can be] [. . .] [Rounds need] at least 10 different people and they pair up in fives and they do different ones, at least every other month, if not every month with different teams and in different settings.

Good administrative support was key to the success of Rounds but was not available to all, and the task fell on the facilitator or clinical lead, which amplified the other challenges.

Many facilitators felt that the onus was on them to make Rounds a success. Given the challenges of measuring outcomes, ‘success’ was often measured by attendance numbers. Most facilitators we spoke to felt that having good monthly attendance figures was an important marker of success, but others felt that to reach a few people was sufficient:

So the numbers don’t necessarily mean all of it and if we change two or three people’s lives in 1 hour then that’s a Round. And that’s why I love it and that’s why I’d want to carry on doing it, because you can’t save a hundred people from emotional woe all in one go. I think it’s baby steps.

Facilitators also highlighted misunderstandings about the purpose of Rounds, as some employees were advised (by management) to attend Rounds to help address problems, grievances and personal issues. This meant that responsibility passed on to Round organisers to deal with issues that would have been better addressed elsewhere. Many suggested that Rounds were a ‘slow burn’ intervention that took time to develop and be effective, and part of the effectiveness was educating staff about how they worked, developing emotional literacy and creating a Schwartz-savvy audience (see Chapter 8). Some facilitators worried that staff would become bored with the repetitive nature of the Rounds format (whereas others suggested that the routine and ritual were important for emotional safety). Some facilitators felt that they would benefit from support and debriefing for their own emotional well-being.

Steering group members’ experiences

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

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

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

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

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

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

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

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

Stakeholder experiences

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

Most spoke positively of Rounds, for example:

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

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

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

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

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

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

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

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

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

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

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

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

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

Non-attenders’ experiences

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

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

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

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

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

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

Chapter summary

This chapter has explored staff experiences of attending, presenting and facilitating Rounds and has highlighted the importance of panel preparation in shaping the stories that were presented and in preparing the panellists for the Round itself. Participants reported that Rounds were interesting, engaging and a source of support, providing useful opportunities to reflect and process the challenges they faced at work. Audience members reported learning more about their colleagues and about patient situations, and this, together with engaging with multidisciplinary colleagues, created greater understanding, empathy and tolerance towards colleagues, and patients and their families. A few reported negative feelings and some were unprepared for the sadness, anger and frustration that they experienced or witnessed in Rounds. Having control over their day (which was less possible for ward-based staff) and a convenient location facilitated attendance, while conflicts with other work/clinical priorities and having no one to cover their work were identified as barriers. Panellists were motivated to present for a number of reasons including increasing visibility, providing learning for others and seeking to be heard or have closure on a difficult issue. Most panellists spoke positively about Rounds, attributing this to the reassurance provided by the facilitator and the friendly reaction of the audience. A few panellists reported being frustrated by the audience turnout or composition, and one person described how the facilitator’s attempts to protect had resulted in an uncomfortable silence.

The chapter also explored experiences of facilitating Rounds. Facilitators were often Rounds champions, having brought Rounds to the organisation, and some felt very responsible for the planning and execution of Rounds. The characteristics of facilitation were identified. Many of these paralleled facilitation in general, in addition to managing emotional disclosure, promoting reflection and discouraging problem-solving. Participants drew on many sources to support them in their facilitation, including former roles that had required similar skills. Experiential and peer learning also prevailed. An alignment with one’s professional values, an activation of positive feelings, professional development and an expansion of one’s professional network were cited as reasons why participants had become involved in Rounds facilitation. Challenges felt by facilitators included having sufficient time to undertake the role properly, or as they would wish, especially as it was often in addition to their usual work. Facilitators felt pressure to make Rounds a success, often with minimal resource. Clinical leads were important Rounds champions and most board interviewees spoke positively of Rounds. Steering groups provided support by sourcing stories and panellists, and debriefing, evaluating and promoting Rounds. Sufficient administrative support and an active steering group were key to Rounds sustainability, and these varied between sites.