Introduction
Our mixed methods, realist-informed, two-phase study aimed to evaluate Schwartz Center Rounds® (Rounds), an intervention to support health-care staff to deliver compassionate care. This chapter describes the background to Rounds in the UK and the structure of the report.
Schwartz Center Rounds®
Rounds were developed over 20 years ago and implemented in North America via the Schwartz Center for Compassionate Healthcare (SCCH), which is based in Boston, MA, USA, and is an autonomous, non-profit organisation (www.theschwartzcenter.org). Rounds were implemented in the UK via the Point of Care Foundation (PoCF), which was established in 2013 as an independent charity and has held the licence with SCCH to run Rounds in the UK since 2009.1 Originally, the Point of Care programme was hosted at The King’s Fund, where the work commenced in 2007. Rounds were inspired by the experiences of a health-care lawyer, Kenneth Schwartz, who became terminally ill with lung cancer and wrote about his experiences of health care in the Boston Globe in 1995.2 Kenneth noticed that ‘small acts of kindness made the unbearable bearable’2 and reminded caregivers to stay in the moment with their patients. He noted how some health-care staff were able to be compassionate while others were not, and how the same staff member could be compassionate one day and not the next. Before his death, he set up SCCH as a non-profit organisation designed to nurture compassion in health-care workers.
Rounds provide a regular (usually monthly) structured time and a safe, confidential setting for all staff employed in all organisational roles to get together to share the emotional, psychological and social impacts of working in health care. The purpose of Rounds is to support staff and enhance their ability to provide compassionate care. Unlike other types of reflective practice interventions, Rounds are a place not for solving problems or focusing on the clinical aspects of patient care, but for sharing the emotional, social and ethical challenges of providing care. Each Round lasts for 1 hour and begins with a multidisciplinary panel presentation of a patient case by the team who cared for the patient, or a set of different patient stories based around a common theme. The panellists each describe the emotional impact that the experience of looking after the patient has had on them. A trained facilitator then guides a discussion of emerging themes and issues, allowing time and space for the audience to reflect with the panel on similar experiences that they have had. Attendance is voluntary and staff attend as many or as few Rounds as they are able. When we began this work in 2013 (initial proposal), Rounds were running in 300 health-care organisations in the USA and 31 in the UK. At the time of writing, 425 health-care organisations are running Rounds in the USA and over 150 are running them in the UK.
The changing context of Schwartz Rounds development in the UK
Between the submission of the grant application for this study in May 2013 and the end of the study period in December 2016, the uptake of Rounds in the UK developed substantially. In May 2013, there were 30 organisations running Rounds, and on past uptake we anticipated that, if funded, there would be approximately 40 organisations running Rounds. By the time we started the project in September 2014, there were 77 organisations running Rounds in England, and we absorbed this additional sample into our mapping study without further resource. By the time we completed data collection in June 2016, there were over 150 organisations running Rounds. Our study needs to be understood in the light of certain events, and the reactions to those events, that occurred during this period (Figure 1).
FIGURE 1 The context of implementation of Schwartz Rounds in the UK in relation to this study. DHSC, Department of Health and Social Care; LETB, Local Education and Training Board. (Figure not reproduced here; see the original article.)
In February 2013, the Francis report3 into the failings in care at Mid Staffordshire NHS Foundation Trust was published. Francis recommended that:
A sense of there being one team for the patient should be fostered where possible. One way to help in this might be to involve staff of all backgrounds in case reviews, clinical audit, and in overall team meetings [. . .] One method whereby this has been achieved has been by Schwartz rounds [sic].
As part of the UK government’s response to Francis in May 2013, funding of £600,000 was granted to the PoCF over 2 years to promote and spread Rounds across the NHS through training and mentorship. Local Education and Training Boards (LETBs) and Macmillan Cancer Support (Macmillan) invited organisations to apply for funding to support the costs of running Rounds, which may have increased uptake.1
In April 2013, the Point of Care moved from The King’s Fund, where it had been since 2007, and became the PoCF. It subsequently developed its own training and support for Rounds organisations in the UK, as well as a membership programme (see Figure 1). (See Chapter 7 for further exploration of this.)
Report structure
In Chapter 2, we detail our aims and objectives and present the methods we have used to answer these, and describe how the wider context of our study has changed over the evaluation period in relation to the publication of the Francis report3 and the adoption of Rounds in the UK. Chapter 3 presents our scoping reviews of the literature and provides a composite definition of Rounds to enable us to compare Rounds with other similar interventions. The results of the survey, interviews and secondary data collation we undertook to map Rounds provider profiles in England are presented in Chapter 4. To determine if Rounds have an impact on staff well-being, we report survey findings comparing new Rounds attenders with staff who had never attended Rounds, from 10 Rounds providers, in Chapter 5. Staff experiences of attending, facilitating, presenting and supporting Rounds as steering group members, together with the experiences of non-attenders and board members, are in Chapter 6. Chapters 7 and 8 support our realist evaluation of Rounds reporting data analysis to support our question: what works, for whom, in what respects, to what extent, in what contexts, and how? Finally, we summarise and discuss our findings and present our conclusions in Chapter 9.