Abstract
Objective
To evaluate the impact of Schwartz Center Rounds, a multi-disciplinary forum to reflect on the emotional consequences of working in healthcare, on the staff of a large acute general hospital over a three-year period.
Design
Evaluation data following each Round were collected routinely from all staff attending over this period and analysed quantitatively and qualitatively.
Setting
An integrated university teaching trust with both acute hospital and community services in the North East of England.
Participants
Over the three-year period of the study, 795 participant evaluation forms were returned by staff attending the Rounds.
Main outcome measures
A standard evaluation form completed at the end of each Round by those present, including ratings on a five-point scale against each of eight statements and an opportunity to offer additional free text comments.
Results
The findings show a very positive response to all aspects of the Rounds by staff who attended. The most highly rated statement was: ‘I have gained insight into how others think/feel in caring for patients’. This was reinforced by the qualitative analysis in which the primary theme was found to be Insight. There were no significant differences between disciplines/staff groups, indicating that all staff whether clinical or non-clinical responded to the Rounds equally positively.
Conclusions
Schwartz Rounds are highly valued by staff from all disciplines, and by managers and other non-clinicians as well as clinicians. They appear to have the potential to increase understanding between different staff, and so to reduce isolation and provide support.
Keywords
Introduction
The quality of care and patient safety in the NHS are under scrutiny as never before, in a context of increasing pressure on performance. 1 High levels of stress are evident among frontline staff, with the attendant risk of burnout.2,3 Yet these same staff hold the main responsibility for providing the compassionate care which is widely and rightly valued – the kind of care we would all want for our ‘friends and families’. 4 There is growing recognition of the relationship between the well-being of staff and the well-being of patients for whom they care.5,6 Increasing attention is paid to staff well-being, and in this context Schwartz Center Rounds are attracting widening interest.
Schwartz Center Rounds (‘Rounds’) provide a multi-disciplinary forum for staff to meet on a monthly basis to discuss and reflect on the personal and emotional impact of working in healthcare. They are open to all staff employed in the organisation, whether clinical or non-clinical. Rounds were first developed by the Schwartz Center for Compassionate Healthcare in Boston, USA in the late 1990s and have steadily expanded. They are now established at over 350 healthcare organisations throughout North America.
In 2006, an evaluation of the impact of Rounds on participating staff was commissioned by the Schwartz Center, Boston. The findings indicated that staff who attended a number of Rounds reported increased insight into social and emotional aspects of care; improved teamwork/communication; appreciation of the roles of colleagues from different disciplines and decreased feelings of stress and isolation. 7 The more Rounds that staff attended, the greater the benefit they experienced. In addition, there was evidence that insights gained through Rounds led to specific changes in departmental and even hospital-wide practices, to the benefit of both staff and patients.
In 2009, The Point of Care Programme at the King’s Fund entered an agreement with the Schwartz Center to undertake a pilot of Rounds in the UK, working with two NHS acute hospital trusts. The purpose was to ascertain whether they would have a similar impact on participants to those reported in the USA. Evaluation of the pilot study took the form of before and after online surveys of participants, and feedback sheets completed after each Round 8 ; and qualitative interviews with a sample of regular participants. 9 The findings indicated that Rounds at the pilot sites had a positive impact on individuals who attended; on staff relationships and team functioning and on the wider hospital culture, by building and supporting shared values. Overall, it was concluded that Rounds could transfer successfully to the UK, and that they were firmly established and valued by staff at all levels at the two pilot sites.
Responsibility for Schwartz Center Rounds in the UK has now passed to The Point of Care Foundation, an independent charity established in 2013. The number of UK organisations contracted to hold Rounds has grown quite rapidly, and currently stands at around 120 NHS trusts and hospices. Several accounts of the impact of Rounds have been published, all favourable and all to date within hospice settings.10–12 Two accounts report brief descriptive statistics, from data collected over a 12-month period, and one of these also reports the findings of four interprofessional focus groups.
In the present study, quantitative and qualitative analysis is undertaken of all the evaluation data collected from Rounds held in an acute NHS trust over a period of just under three years.
Schwartz Center Rounds at South Tees
South Tees Hospitals NHS Foundation Trust provides district general hospital services for the local population, and also a range of community services. In addition, it offers a number of specialist regional services to 1.5 million people in the Tees Valley and surrounding area, with a particular expertise in heart disease, neurosciences, children’s services, renal medicine, cancer services and spinal injuries; and it is the major trauma centre for the southern part of the northern region.
It has a total workforce of around 9000.
Schwartz Rounds were first introduced at South Tees in January 2012, following the guidelines developed by the Point of Care team at the King’s Fund from the work of the Schwartz Center. All staff in the Trust whether clinical or non-clinical are invited to attend. A panel of three to four speakers – usually from different disciplines – spend around 20 minutes presenting a patient story, or talking about a topic related to their work. The emphasis throughout is on the personal and emotional impact of their work, and only touches on the detail of clinical management as necessary to explain the story.
A Round lasts for one hour, and for the remainder of this time the discussion is opened up to all those attending under the guidance of two facilitators, a clinical psychologist and a doctor. It is emphasised that the purpose is not to solve problems but to reflect on the stories told, and to share experiences these may have brought to mind. The need for confidentiality is stressed, in relation to any patient stories, and to any participants speaking during the Round. The intention is to provide a safe environment in which staff feel able to talk freely. (These principles are all shared in common with other centres where Schwartz Rounds are held.)
At the first Round held at South Tees, three senior members of the medical staff each spoke about a memorable patient, where the outcome had not been good. They talked about their immediate reactions when something went seriously wrong, and about their lingering feelings of responsibility. The title of the Round was: ‘Does this make me a bad doctor?’ There was complete silence as they spoke. Staff in the audience said later that it had altered their views of the three speakers and of doctors generally – as being human and having feelings like everyone else. Other Rounds since then have seen numerous patient stories; presentations by several teams including Palliative Care, Organ Donation and the Acute Assessment Unit and a group of junior doctors talking about their experiences on night shifts.
Rounds are held in the middle of the day, and a simple lunch is provided beforehand. The number of staff attending over the period of the study ranged from 56 to 97 (mean attendance 71.3). The aim is to hold 10 Rounds each year – on a monthly basis apart from August and December. Feedback is requested from each individual attending by means of a one page evaluation form (see Figure 1), which is completed immediately the Round ends. The responses on these evaluation forms collected over a three-year period are the subject of the remainder of this paper.
Schwartz Center Round evaluation form.
Evaluation of rounds at South Tees
Respondents
Over the course of 18 Rounds in a period of just under three years, 795 responses to the evaluation form were collected. The breakdown of respondents by profession was as follows: nurses – 36%; doctors – 18%; allied health professionals/other clinical – 14%; administrative/managerial – 9% and other (social worker, chaplain, domestic, porter, volunteer) – 20%. (This compares to a breakdown of the overall Trust workforce of: nurses – 43%; doctors – 9%; allied health professionals/other clinical – 10%; administrative/managerial – 20%; other – 18%.) We also received 158 qualitative comments from nurses (39%), doctors (18%), allied health professionals/other clinical (9.5%), administrative/managerial (15%) and other (16.5%). It is not possible to estimate the extent of repeat attendance within these figures, as the forms are completed anonymously.
Quantitative analysis
Method
The numerical responses to the evaluation form items were recorded onto Excel and subsequently transferred into R (R Development Core Team, 2008) for analysis.
Results
Means, standard deviations and total respondents for each of the eight statements in the questionnaire.
Responses to all eight statements listed on the evaluation form were highly correlated and could be seen as forming a single scale (Cronbach’s alpha = 0.85). An ANOVA showed that there was no significant effect of profession on the total score on this scale (F = 0.045; df = 4667; p = 0.996). This indicates that all professional groups (nurses, doctors, allied health professionals, administrative staff and others) responded to the statements in a similarly positive fashion.
The statement on the evaluation form receiving the highest mean rating (4.79) was ‘I have gained insight into how others think/feel in caring for patients’. A paired t-test showed that there was a significant difference between the mean of the highest rated statement (Insight) and the mean of the second highest rated statement: ‘I plan to attend Schwartz Rounds again’ (t = 2.71, df = 750, p < 0.01). This finding is again reinforced by the thematic analysis below, where the theme of Insight was ranked first in importance.
Qualitative analysis
Method
Thematic analysis was undertaken of all free text additional comments recorded on the evaluation forms, in accordance with the principles described by Braun and Clarke. 13
Initial coding was carried out by two of the authors independently (RC) and (BH). On the basis of their initial responses to the data, they generated a number of codes representing meaning units. They worked through the comments identifying meaning units and allocated these a code. The resultant codes were reviewed and those similar in meaning were clustered together to form higher order codes or themes.
The two coders then met to compare codes with a third author (SM) present to validate the process. By adopting two levels of clustering – basic codes to subthemes and subthemes to higher order themes – a satisfactory thematic analysis was achieved.
Results
Themes, subthemes and codes arising from thematic analysis (numbers in brackets represent the number of comments coded under each heading).
The single most frequently occurring theme was termed Insight, signifying some new understanding or perspective. This was divided into two subthemes, focussing either on the speaker at the Round (one or more of the team making the presentation) or on the respondent him- or herself. Within the subtheme Insight: Speaker the first group of comments reflects increased understanding of the perspectives of other staff, for example: As a radiotherapy physicist, I don’t often deal with patients directly. However I work closely with those who do and it was interesting and helpful to gain insight into such people’s experiences. I work in Public Relations and found it very interesting and useful to hear staff talk about their feelings re bed pressures, as I usually only hear frustrations from the patient’s family. As a junior doctor, sometimes the confidence is very minimal when a well patient becomes poorly, but to see a perspective from a senior consultant, it gives a lot more meaning and enthusiasm to care for patients.
The second group of comments reveals an awareness of some emotional response within the speaker(s): A very good insight into how surgeons feel because they give off the opinion that they are ‘God’. It was really useful to hear how all professionals feel when under ‘attack’ from patients … even medics. Very open and honest. Insight into how lonely young doctors can be at work.
A third and final group of comments shows recognition of staff needs for emotional support: I would be interested in how the organisation will support these people and other people in similar situations. I think we don’t consider the human cost of traumatic experiences enough. Need for debrief and review is massive, especially after traumatic deaths.
The second subtheme – Insight: Self – concerns some new understanding of oneself. The first group of comments relates directly to the respondent’s own emotional reaction, and testifies to the strength of emotions evoked in the audience: It was all I could do not to cry! Very emotional. Deeply moving and emotional. Inspirational and heart wrenching. Gave me an excellent insight into the thoughts and feelings of other professionals which will change the way I think about and care for my patients.
Comments in the second group go beyond an emotional response, to identify resonance with their own experience: I’m very glad I attended this meeting – it makes my difficult patients a bit easier to handle. Very good, makes you reflect on your own difficult experiences.
The third group of comments indicates some form of intention for the future. In some cases, this is simply a wish to attend further rounds: Definitely like to attend again.
In other cases, there is a sense that future practice will change: Gave me an excellent insight into the thoughts and feelings of other professionals which will change the way I think about and care for my patients. An interesting dilemma which we see in oncology. I sometimes have thought what are we doing in certain cases, just because we can should we? … I’ve found this difficult as a clinician.
The second main theme identified was a simple expression of gratitude and was termed Appreciation. So, for example: Thank you for the openness and honesty of discussion. Excellent – very honest. Raised some sensitive and difficult issues. Thank you.
The third main theme concerned factors relating not to the content of the Round, but rather to the Conduct of the meeting. One group of comments reflected the emotional atmosphere of the Round: The atmosphere was very comfortable – relaxed, mutually supportive and very positive. Particularly liked the ‘human’ aspect and allowing staff to express their feelings without judgement.
A second group of comments referred specifically to the quality of facilitation: Well and sensitively facilitated. Skilfully facilitated
The fourth and final main theme concerned a range of practical factors and was termed Suggestions for improvement.
One group of comments indicated that Rounds should be made available to wider staff groups: Need more ward staff to attend. Would be better to have a greater cross section of staff – minimal number of HCAs/porters/staff nurses.
The remaining suggestions were of purely local interest and have not been included here.
Discussion
The evaluation results confirm the very positive findings of previous studies both in the USA and the UK in relation to overall staff response to Rounds. There is also a new finding – namely that all groups of staff (whether clinical or non-clinical) are alike in rating the Rounds highly. This is of course the underlying intention of the Schwartz Rounds model, to engage with all members of a healthcare community regardless of their professional background, and it is encouraging to see this fully supported. Perhaps this is because the feelings described by those who present at Rounds – sadness, worry, regret, satisfaction, anger, relief and so on – are universal human reactions. The stories are about the human aspects of the work we do – and these concern us all.
The highest rated statement on the evaluation form – significantly higher than the other statements – is: ‘I have gained insight into how others think/feel in caring for patients’. This is amplified by the qualitative analysis, where the most prominent theme – Insight – reflects not only new understanding of others and their roles, but also a new awareness of the individual’s own responses. Taking first the focus on others, the individual comments indicate a better understanding of colleagues – non-clinicians of clinicians, juniors of seniors and vice versa – both in terms of what they do and how they feel. There is also acknowledgement of the emotional cost of working in healthcare and the need for personal support. Secondly, the focus on self includes comments testifying to the emotional impact on individuals attending Rounds, and beyond this a resonance between the speakers’ feelings and their own. This recognition of common emotional ground appears somehow to validate and also to promote understanding and acceptance.
One final group of comments under the theme of Insight indicates some form of future intention. This bears directly on a crucial question about Schwartz Rounds – what impact do they have, and does anything change as a result? A number of comments refer simply to the wish to attend further Rounds in future. Others hint at something less tangible – a change in attitude, or in the way in which judgements are made. It is as if Rounds provide a protected space within which to reflect on one’s own experience and practice. As yet we know little if anything about actual changes that follow outside the Rounds. It would be interesting to find ways to explore this further.
The second main theme emerging from the analysis is Appreciation. Comments frequently include words like ‘honest’, ‘open’, ‘thoughtful’ or ‘thought-provoking’. Increasing pressures in healthcare mean there is often no time for the day-to-day contact and conversations which help staff to understand each other, and how they are managing their work. 14 Within this context, Rounds help to increase understanding between colleagues, and so reduce isolation and provide support. In this sense, they may help to mitigate the effects of ‘silo working’ that are often found in NHS trusts.
Many of the comments within the two main themes bear witness to the powerful emotional content of Rounds. There is clear recognition of the feelings disclosed by speakers and the answering emotions elicited in those listening. A worry commonly expressed in trusts considering holding Rounds is that they will bring up emotions which cannot be contained either by the individual or by others in the room, and in this sense may cause harm. However, what gives rise to powerful emotions is the daily experience of working in healthcare – Schwartz Rounds simply provide an opportunity to put them into words. The organisers have avoided offering advice along the lines: ‘if you have found this discussion upsetting, you can seek support … ’ as this risks implying that strong feelings are inappropriate or out of place – rather than something to be expected. The comments reported here suggest that staff attending Rounds respond to emotion constructively, but vigilance against possible harm is still important.
The fact that staff are at ease with an unusual degree of emotional expression reflects their trust in the setting provided by the Rounds. Several comments within the third theme – Conduct of the meeting – refer to the atmosphere as being safe, comfortable and non-judgemental. Other comments refer to skilful or sensitive facilitation. The role of facilitator is crucial in setting the tone for a Round, eliciting feelings and managing the boundaries which ensure safety. In this they receive training and support from The Point of Care Foundation. 15
The final main theme – Suggestions for improvement – includes a concern that Rounds should be available to a wider cross section of staff – particularly more ward nurses, health care assistants and ancillary staff. This is probably the single issue to which the Steering Group devotes most time in discussion and remains a challenge.
There are a number of limitations to this study. Although the data were collected over a period of almost three years, they were taken from a single site. Further studies are needed to see whether the findings are replicated. Also the qualitative analysis was based on written comments rather than interviews – an opportunity to probe the comments would lead to fuller understanding. Finally, the method adopted here did not study the effects of cumulative attendance at Rounds, as reported in the US study,
7
nor is it known how many respondents attended more than one Round. Despite this, the present study provides an evaluation of Schwartz Rounds in a large acute healthcare trust over what we believe to be the longest period to date. It demonstrates the high regard in which they are held by all staff groups alike, clinical and non-clinical. There is in addition anecdotal evidence of a ‘ripple’ effect throughout the larger organisation. This will be the subject of a future study, but the comments of one presenter after speaking at a Round bear witness to some wider influence: The most interesting – and somewhat unexpected – thing that has come out of my team’s presentation is how many managers suddenly understood what (x type of) care was all about – and they say this to me often.
Footnotes
Declarations
Acknowledgements
Thanks to Esther Flanagan, Point of Care Foundation, for her comments on an earlier draft of the article.
Provenance
Not commissioned; peer-reviewed by Ian Watt.