Abstract
Objective
To assess (1) whether the Schwartz Center Rounds (“Rounds”), a multidisciplinary forum which brings together hospital staff to discuss the nonclinical, social and emotional aspects of caring for patients, could transfer from the US to a UK setting; and (2) whether UK Rounds would achieve a similar positive impact on individuals and teams, and hospital culture.
Design
The results reported are based on 41 qualitative interviews with context provided by additional quantitative research.
Setting
We introduced Rounds at two pilot sites, both NHS hospitals providing acute care.
Participants
Over the one-year, ten-Rounds pilot period, Rounds were attended by 1250 staff across the two sites. We conducted qualitative research into the experiences of staff involved in implementing Rounds at the outset and the end of the pilot.
Main outcome measures
Interviewees' assessment of the effects of Rounds on participants, their relationships with colleagues, and the wider hospital.
Results
The findings show that in the two pilot trusts, Rounds are perceived by participants as a source of support and that their benefit may translate into benefits for patients and team working; and that Rounds have the potential to effect change in the hospital culture.
Conclusion
Rounds appear to transfer successfully from the US to the UK, and there is some evidence that they are having a similarly positive impact, but more research is needed.
Introduction
There are high levels of stress among NHS staff. 1 Stress can lead to burnout and loss of ideals; 2 and get in the way of compassion and empathy. 3 There is an important relationship between the well-being of staff and the well-being of patients. 1,4,5 The Schwartz Rounds® are a practical method of supporting staff well-being.
Developed by the Boston-based Schwartz Center for Compassionate Healthcare (
Rounds have been running in hospitals in the States for over 14 years, steadily expanding to over 200 sites throughout the country. In 2006, the Schwartz Center for Compassionate Healthcare commissioned research to evaluate their impact on participating staff. Their research findings demonstrated that following Rounds, participants reported better teamwork and perceived themselves as experiencing less stress; Rounds also enhanced participants' ‘likelihood of attending to psychosocial and emotional aspects of care and enhanced their beliefs about the importance of empathy’. Furthermore, the impact of Rounds on these outcomes increased with the number of Rounds participants attended. 7
In 2009, the King's Fund's Point of Care programme entered into an agreement with the Schwartz Center to work with two NHS acute hospital trusts to pilot Rounds in the UK – the first expansion of Rounds internationally. This paper describes the evaluation of the UK pilot, which sought to assess (1) whether Rounds were transferrable to the UK, and (2) whether impacts similar to those observed in the US would be seen in the UK setting.
Format of Rounds
Rounds at UK pilot sites followed the same format as those in the US. A pre-selected panel, led by a doctor and including one or two other staff involved in the patient's care, spend 10–15 minutes presenting a case story and describing their role, the issues the case raised for them, and how this made them feel. Under the direction of a skilled facilitator, discussion then opens up for the remainder of the hour to the larger group of participants, who ask questions, share experiences and reflect on the challenges of care. Participants are encouraged not to problem-solve but to consider the implications of the case for staff. Rounds are designed to be a safe and confidential environment: aliases are used to protect confidentiality. Rounds are generally held over lunch, with food provided for participants.
Except for a Christmas and August break, UK pilot sites held Rounds monthly. Starting in October 2009, the pilot comprised the first 10 Rounds held at each site, spread over a 12- to 13-month period.
Rounds are open to all hospital staff and organizers publicise forthcoming Rounds in a variety of ways. Over the pilot period, Rounds were attended by 1250 staff across the two sites (See Table 1 in Appendix 1, which can be found at
Pilot sites were two NHS trust hospitals providing acute care, one a 480-plus-bed hospital in the west of England (‘Spa Town’) and the other a 1000-plus-bed hospital in London (‘Central London’).
The Evaluation
We undertook a three-pronged approach to evaluation, to explore whether Rounds “translated” to the UK context, both in process and in ethos, and what impact they had on participants and their working relationships:
Pre-/Post-Pilot Surveys
To assess whether Rounds have an impact on participants and on their individual conversations with colleagues and relationships with patients, we conducted before and after surveys of participants, replicating the questionnaires used by Lown and Manning.
7
Respondents could complete the first survey online or on paper; and the second survey online. There was a low response rate, and we do not report on these data here. (Discussed further in “Schwartz Center Rounds: Evaluation of the UK pilots”
Feedback from each Round
We tracked attendance and collected feedback from participants via one-page evaluation sheets at the end of each Round. These data helped the organizing committees to monitor the quality of Rounds, respond to any logistical concerns, describe the participant demographics; and plan future Rounds. (Discussed further in “Schwartz Center Rounds: Evaluation of the UK pilots”
Qualitative Interviews
Qualitative research, based on the experiences of staff involved in implementing Rounds, was conducted at the beginning and end of the pilot year. Almost all staff were interviewed on their own, either face to face or by telephone. At the time of the first interviews, trusts had held between one and three Rounds; at the second interviews, Rounds had been running for at least a year, with a minimum of ten Rounds held at each site. It was a purposive sample, representing regular Rounds participants from a range of occupational and professional backgrounds. 18 people were interviewed at the start of the pilot year, and had all been involved with Rounds, either having attended at least one Round (17/18), been a member of the organizing committee (14), a panellist (2) or facilitator (2). Of the 23 interviews at the end of the pilot year, 11 were on the organizing committees, 4 had been panellists, and 4 were facilitators. No attempt was made to pursue people who had not attended Rounds. The number of interviewees was pragmatic and resource driven. Thirteen were interviewed twice, both at the beginning and end of the pilot year to see how views may have changed or developed. None of those approached to be interviewed refused.
The qualitative research was designed to explore the views of senior leaders and the key players involved in the establishment of Rounds: what they hoped the Rounds would contribute to the life of the hospital, how they were related to the trust's strategy and what impact interviewees had observed or expected to observe (See Appendix 2 which can be found at
This paper reports on findings from the qualitative interviews.
Results
Establishing Schwartz Center Rounds in two English trusts
Although well established in the States, this is the first time Rounds have been run outside the US. Our first point of enquiry, therefore, was to examine whether Rounds would transfer to a UK hospital setting.
Some respondents in the qualitative interviews suggested that the American origins of the Rounds offered both an opportunity and a potential obstacle for pilot sites. The evidence from the US on the efficacy of Rounds was seen as a source of credibility, but organizers worried about perceived differences between American and British attitudes about open discussions regarding the emotional aspects of caring.
We have done quite a lot to try to promote it. We've targeted medics and clinical teams, and the feedback is that it has potential. There was some anxiety about whether it would translate from the US to the UK, i.e. would people talk openly about their emotions? They did! (Organizing committee, site 2, phase 1)
Some hardened surgeons have appreciated these Rounds and have been vocal participants. That has surprised me! (Panellist, site 2, phase 2)
A change over time can also be observed in the way that several people became more supportive of the Rounds as the pilot progressed, once they had seen them work in practice:
I overwhelmingly endorse them. I was a sceptic and now I am a convert. Initially I just came along as I am a clinical leader to show support. (Participant, site 2, phase 2)
There was always a high level of support from the board and now some of the sceptics are less sceptical. (Organizing committee, site 2, phase 2)
Strong board support is very important for anything where you wish to see changes.
Support from the top of the organization is good. The Chief Executive has been to one or two, and the Chair has been to several. (Organizing committee, site 2, phase 2)
Impact of Rounds
Our findings suggest that participants perceive UK Rounds as having personal benefit, influence on relationships with colleagues and in teams, and wider effects on the organization. Themes from the qualitative research are explored below according to these groupings, moving from the individual out to the level of the institutional.
Impact on individuals
Following attendance at Rounds, staff felt that they provided patients with more compassionate care, and felt less stressed in their work with patients.
People have found it really helpful. It has given people a focal point to talk about their roles. It can be brutalising to be compassionate all the time. (Organizing committee, site 2, phase 2)
I really appreciated the language. You hear words used you don't normally hear such as anger, guilt, shame and frustration. They are obviously there, but there is no outlet for them. (Participant, site 2, phase 2)
People are taking the concerns of staff seriously – opening ourselves to hear what people are struggling with. And in the context of mid-Staffs – staff are expressing things, and the Rounds are a sign that it is safe to speak. It is all very well to say we have an open culture, but this demonstrates that value. (Organizing committee, site 1, phase 2)
Impact on teams/relationships between staff
A large number of interviewees (both clinicians and non-clinicians) felt that the Rounds were helpful in increasing respect, empathy and understanding between staff:
It is very grounding. It is humbling. You think – Christ, this is what they do! It reminds you of the profound ethical decisions people take. (Participant, site 2, phase 2)
Anecdotally, nursing staff, physios, all staff really, say they have a greater sympathy for doctors, who seem less cold and hard. And doctors have greater respect for the rest of the team as you appreciate what they do and what they are having to take home with them. (Organizing committee, site 2, phase 2)
Quite a few who are “famous” in the organization have been seen differently, as more compassionate. And they are starting to reflect on how they are perceived. (Organizing committee, site 2, phase 2)
It is valuable for a junior doctor to see a senior doctor say “this really upset me”, or “I f***** up
”.(Organizing committee, site 2, phase 2)
It is a shared experience. When you talk about difficult patients, everyone has similar feedback. Most people don't normally talk about those things. I normally talk about it to other consultants, but not to other levels or other professional groups. (Panellist, site 2, phase 2)
Generally we are quite siloed and some teams work more collaboratively than others. People do need to acknowledge the impact of their work on each other. Schwartz is likely to affect how they work together. (Participant, site 2, phase 2)
Impact on wider hospital/culture
There was some feeling that the Rounds made the hospital environment less hierarchical by providing a forum where people could meet and discuss as equals, with recognition for the similar feelings that people in different roles and at different levels of seniority shared:
There is always hierarchy in a hospital but in a room like that you are all carers in a caring environment. Your opinion is listened to. It is about breaking down barriers. (Participant, site 2, phase 2)
Overuse of targets, results in people feeling beaten rather than inspired.…a benefit of Schwartz is that it … counterbalances some of the targets stuff and humanises the mix. (Panellist, site 2, phase 2)
Happy staff create happy patients. We haven't done well with our staff or patient survey, so Schwartz is part of creating happy staff. (Organizing committee, site 2, phase 2)
It generates pride in our identity. We need to re-emphasize that we are here to care for patients, so we need to look after staff. (Panellist, site 2, phase 2)
I do see the Schwartz Rounds as having a symbolic value, of saying “we value this”. And if we keep valuing it, I‘d expect it to have significant consequences. (Participant, site 2, phase 2)
Discussion
There are some study limitations: the first interviews were at an early stage in the pilot and the second were after just under a year. It may take longer for people to appreciate the impact of the Rounds. The perceived impact on staff behaviours and communication with patients is only self-reported. We did not explore why some staff have chosen not to attend. However, the research covered a good range of interviewees who were able to speak freely to an independent researcher. Half were re-interviewed at the end of the pilot period and could reflect on how the Rounds had had an impact over the year.
Findings were very similar between both sites and suggest that Rounds have the potential to have a positive impact on staff at all levels of the hospital, with improved teamwork, improved empathy, and sense of working in a supportive environment, all reported.
Rounds may also provide a role modelling opportunity, as senior staff not only acknowledge their own challenges but simultaneously model to junior staff the importance of discussing the emotional side of caring for patients. However, they should be seen as just one in an array of initiatives to support staff. Notably, it is a relatively low-cost way of doing so: outlay includes the cost of lunch for staff, costs for venue booking and the time required for facilitation and administration.
Further research is needed: once Rounds have been running longer and in more sites (so far currently running in 10 sites) there will be potential, with an enhanced sample size and greater statistical power, to replicate Lown and Manning's quantitative research to explore the impact of Rounds in different professional groups, and to see how impact changes over time. 7
Conclusion
The qualitative research suggests that over the course of a year, two English trusts have shown that Schwartz Center Rounds can transfer to a UK NHS context. Rounds appear to be valued by staff at all levels and are firmly established in the two pilot trusts, providing a good foundation for their future spread.
DECLARATIONS
Competing interests
Not applicable
Funding
Not applicable
Ethical approval
Ethics approval was given by Spa Town Trust R&D
Guarantor
JG
Contributorship
Not applicable
Acknowledgements
Thanks to the two pilot hospital trusts, their Rounds' clinical leads and facilitators, and Marjorie Stanzler and Beth Lown M.D., of the Schwartz Center for Compassionate Healthcare
Reviewer
Marilyn Kendall