Realist evaluation

Chapter overview

This chapter, as well as Chapter 7, reports the key findings from the realist evaluation. The data reported here include the interview and observation data from the nine case study sites (see also Chapters 3 and 6) and data from the telephone mapping interviews (see Chapter 4).

Aims and objectives

We aim to understand how Rounds ‘work’ in the UK, for whom and in what contexts; to suggest ways to improve their effectiveness; to inform decisions about their implementation in other contexts; and to understand what is causing variations in implementation or outcomes (objective 12).

There were four further objectives:

1. to identify and evaluate changes that take place in relationships between staff who attend Rounds and their patients and colleagues, including any reported behaviour change towards patients and colleagues (objective 11f)
2. to identify the programme theory and mechanisms by which well-being and social support might be influenced (or not) by:
   1. variance in facilitation (objective 11b)
   2. team hierarchy and teamwork and on coping with stress (objective 11e)
   3. wider ‘ripple’ effects felt in day-to-day practice (objective 11g).

Methods

Realist evaluation

Realist evaluation is concerned with the identification of underlying causal mechanisms that explain how an intervention such as Rounds works, for whom it works and under what conditions. Causal mechanisms are always embedded within particular contexts and social processes, meaning that Rounds might work differently in different situations and circumstances. The overarching aim in a realist evaluation is to understand the complex relationship between these mechanisms and the effect that context has on their operationalisation and outcome. This is summed up as context + mechanism = outcome.4 This is subsequently represented as context–mechanism–outcome (CMO) configuration. The CMO configuration is used as the main structure for realist analysis.4 It is a heuristic device/proposition detailing what it is about an initiative that works, for whom and in what circumstances, and is used to generate causative explanations.87 From an iterative analysis process of scrutinising mechanisms, context and outcomes, we propose some theoretically generalisable features about Rounds (i.e. refined CMO configurations)88 (see Report Supplementary Material 9).

Setting and participants

Four members of the research team undertook 177 semistructured interviews with Rounds attendees, facilitators, steering group members and panellists in nine case study sites (see Chapter 6) and observed 42 Rounds in eight case study sites (see Chapter 7; it should be noted that we could not observe Rounds in Horse-chestnut).

Data collection

One of two researchers (ML and ER) led data collection in four or five case study sites from September 2015 to June 2016, supported and supervised by the PI (JM).

Interview and observations

The interviews were initially quite open, with interviewees asked how they understood Rounds to ‘work’, how they identified and explained any changes that generated outcomes, and which aspects of the Rounds process were key mechanisms in this (see Appendix 19). Some interviewees found this easier than others. Subsequent interviews built on mechanisms identified in findings from phase 1 interviews and initial phase 2 interviews (see below). In such a complex intervention, where mechanisms and outcomes are not easily visible (taking place in the minds and later behaviour of participants), interviews with key informants (i.e. experienced audience members, panellists and facilitators, who had thought about how Rounds ‘worked’ and changed behaviour) were most beneficial. Our interviews developed over the data collection period, focusing on one or more key mechanism and testing ideas and theory with new, and at times the same, participants, to explore and test our emerging CMO configurations.

In each case study site, we observed a minimum of four Rounds (43 in total) (apart from Horse-chestnut). Observations were usually undertaken by one member of the team, but two members observed at least one Round in each site to enable them to compare notes and generate discussion. The focus of our observations shifted as data collection progressed and we identified new candidate programme theories to ‘test’. All field-notes captured the number of attendees, the room layout, the number of facilitators, the topic, and the number and role of panellists, and captured the key moments and elements of the Round. As data collection progressed, the team focused on some aspects of Rounds more specifically, for example the facilitator role and how emotional safety was supported or compromised; the use of silence; the use of Rounds ‘rituals’ and rules; and how the audience responded and supported safety in Rounds (or not). We also sought to identify the contexts and specific conditions in different sites that influenced Rounds mechanisms (see Chapter 7).

Data analysis

Realist data analysis is driven by explaining change brought about by an intervention and suggests that programmes offer resources or opportunities, but the decision-making of participants causes the outcomes (it is still necessary for the programme to be implemented as intended for it to be effective; see Chapter 7).5 Data analysis and data collection were undertaken concurrently and we focused our initial realist analysis on interview data with Rounds key experts to search for CMO configurations to find support for causal explanations.

Interviews were multistaged and served different purposes at different phases: theory gleaning, theory refining, theory testing and consolidating interviews.8 We drew on our own expertise gained through observing key Rounds stages, such as panellist preparation, Rounds and steering group meetings, to develop, test and refine our candidate programme theories (CMO configurations) (Figure 8).

FIGURE 8 Data analysis process. (Figure not reproduced here; see the original article.)

We systematically analysed a selection of key experts’ (facilitators and clinical leads) interviews for CMO configurations and causal explanation (across all case studies), and labelled the CMO components in author comments in Microsoft Word (Microsoft Corporation, Redmond, WA, USA) to enable us to review each other’s CMOs and discuss. Five members of the research team (JM, ML, ER, CT and IM) read and analysed the same four transcripts, and discussed and compared analytic categorisation and notes. The team then analysed up to 10 transcripts each, identified overlap and colour-coded data sections relating to context, mechanism and/or outcome (see Figure 8), and discussed these in 10 half-day meetings, with and without support from Justin Jagosh, our realist methodology expert and mentor. We initially generated 29 CMOs and organised them across the four stages of our Rounds model (see Figure 7), and by key player (audience, facilitator, clinical lead or panellist). Further analysis cycles and testing causative configurations in repeat interviews with our well-informed ‘experts’ and two focus groups with Rounds mentors allowing us to refine and collapse our 29 CMO configurations to the nine presented below. Finally, in meetings with Justin Jagosh, we grouped and causally linked our nine CMO configurations together (see Figure 10).

We revisited our initial programme theory and refined this in the light of our CMO data to develop our evidence-informed programme theory (see below). Report Supplementary Material 10 provides a summary of nine data themes that informed our revised CMOs and their inter-relationships.

Our field notes of observations of Rounds, steering groups and panel preparation were managed and analysed as textual qualitative data.89 We followed steps 3–6 above for our field notes on Rounds to examine data to confirm or disconfirm our CMO configurations. We organised our data in Microsoft Word files and using some aspects of framework analysis to determine key descriptive elements across panel preparation and Rounds observation field notes, for example the timing and stages of Rounds; where and how facilitators intervened to support panellists or audience members and maintain safety (or not); and, in panel preparation, how facilitators gathered information and supported panellists to craft stories (including safety and trust aspects). We have not been able to include many fieldwork data from Rounds owing to the sensitivity of the material and the challenges of maintaining anonymity and confidentiality.

Findings

Here we present our initial and evidence-informed programme theory to give a broad overview of how Rounds work. We then present our detailed CMO configurations, explain their inter-relationships and provide supporting data.

Programme theory

All programmes or initiatives will (implicitly or explicitly) have a programme theory, or theories,6 about how the programme is expected to cause its intended outcomes.

Specific data used to develop our initial programme theory included our:

• initial review of the literature to identify mechanisms of Rounds to enable us to design our survey (see Chapter 3)
• composite definition of Rounds in our literature review (see Chapter 3)
• interviews with programme architects in the USA (see Chapter 3)
• initial observations of Rounds and discussions with key players in UK implementation
• review of programme documentation including SCCH in Boston and PoCF websites and contracts.

These approaches enabled us to develop initial programme theories about how, for whom, and under what circumstances the Rounds help health-care staff with the human dimensions of their work (Box 3).

Our initial programme theories (highlighting the underlying psychosocial mechanisms providing the active ingredients to facilitate change), suggested that Rounds ‘work’ by:

• providing an inclusive multidisciplinary group with a level playing field for reflection and discussion in a safe, non-judgemental space to encourage communication between staff who support and teach each other how to better connect with patients and provide compassionate care
• providing social support for staff where disclosure makes events comprehensible and buffers distress and a supportive environment to encourage people to share and learn from the non-medical aspects of their work (not problem-solving), which strengthens the patient–caregiver relationship through empathy
• having a range of attendees, including doctors; the programme provides a forum for all staff (because all staff can influence patient experience and connect with patients) and creates an opportunity for (senior) staff and facilitators to role model vulnerability, which encourages participation and gives permission for others to speak freely and honestly
• having visible organisational support to make evident the organisation’s values on the importance of connecting with patients and supporting staff and role modelling that this matters to leaders to show what works with patients (see Chapter 7 for details).

When a programme like Schwartz Rounds is implemented, it is testing a theory about what ‘might cause change’ (p. 1), even though that theory may not be explicit.5 When we started, we found that the theories or mechanisms by which change might occur were not very explicit (see Box 3). Thus, a key task in our realist evaluation was to make the theories within the programme explicit, by developing clear hypotheses about how, and for whom, programmes might ’work’ (see Chapter 3).

Revised evidence-informed programme theory

Box 4 details our refined programme theory, informed by the evidence from our study, through an iterative CMO configuration process, distilling from the configurations how the Rounds (the programme) cause their intended outcomes based on an analysis of our data.

Adherence to the core components of the Schwartz Rounds model (e.g. group intervention with good facilitation and the creation of a safe space) (see Chapter 7) provides support for staff with their work in health care. It ensures an opportunity for staff to feel safe enough to reveal themselves as human and vulnerable, and for those emotions to be contained in Rounds. This reduces shame, stress and anxiety and improves coping, allowing staff to process difficult emotions and experiences, making themselves more emotionally open and available to patients and colleagues (and self), fostering empathy, compassion and an acceptance of the grey areas and messy realities of emotional work in health care.

When staff are given an opportunity to share experiences and disclose previously hidden experiences, peers get to know each other better, creating greater trust and empathy for each other and improved connections and teamwork.

Stories that reveal the difficult, demanding and satisfying aspects of health-care work, and that provide multiple perspectives on staff and patient experiences, help staff to make sense of their experiences and communicate these to others, creating empathy and compassion for actors in the story (patients, family members and staff) and enable staff, patient and carer behaviours to be seen in context rather than in a one-dimensional way, reducing stereotyping.

Staff group reflection on stories/experiences (that resonate and trigger reflection) create a recognition of shared experiences and feelings, reducing isolation and creating a cohesive community in which staff offer and receive help and encourage and inspire each other, creating support, adaptive coping and motivation for future health-care work.

By putting staff experience at the centre of Rounds, creating a countercultural space that is not outcome orientated, Rounds create an important time when staff are present with each other. This creates openness and honesty, validating conversations about the difficult emotions associated with health-care work and making them culturally acceptable, and shifting conversations in the organisation towards more openness, honesty and compassion for each other.

Rounds, by being open to all and multidisciplinary, enable staff to recognise they are not alone, that others feel the same and that all roles and stories (highly visible or invisible) are valued and important for patient care, which strengthens teamwork and creates a more unified community and stronger ethic of working together.

Witnessing peers and senior colleagues being courageous and role-modelling vulnerability is contagious, inspires others to be honest and allows staff to see colleagues as human, breaking down barriers and creating a level playing field, which can facilitate support and increase challenge and patient safety.

Rounds work by having a cumulative effect over time, with the intermediate outcomes of one Round (increased trust and empathy) becoming a resource for the next Round by creating a Schwartz-savvy audience who support the facilitator in ensuring safety and containment, building trust and a supportive community.

We found that there was less evidence of specific ‘teaching’ than our initial programme theory had implied, although participants spoke of providing learning for others, but we did identify that Rounds strengthen empathy, compassion and relationships between staff, as well as strengthening the patient–caregiver relationship. We also found that visible organisational support had pros and cons (see Chapter 7). Our revised programme theory provided greater insights into how Rounds generated their effects (see above) and we identified some additional mechanisms, including:

• the importance of resonance as well as reflection
• the importance of containment and trust as well as safe and non-judgemental space
• the key mechanism of storytelling and the important role of panel preparation for crafting and telling powerful emotional stories of staff experiences
• that the impact of Rounds develops over time and has a cumulative effect
• the mechanism of contextualising patients and staff and shining a light on hidden roles and stories
• that Rounds provide a countercultural third space (see below).

We now provide a detailed exploration of our refined CMO configurations, which informed the revised programme theory (see Box 4).

Cumulative and linked context–mechanism–outcome configurations

Our findings (CMO configurations) are cumulative and linked.

Cumulative impact of stages of Rounds

In Chapters 6 and 7 we presented our Rounds stages diagram (see Figures 6 and 7). Here we illustrate where our analysis suggests that the nine CMO configurations map across the four stages (Figure 9). It can be seen that not all CMO configurations work across all four stages, with self-disclosure, contextualising patients and staff, reflection and resonance, and group interaction occurring only in panel preparation and Rounds, and not in stage 1.

FIGURE 9 The CMO configurations mapped to the stages of Rounds. (Figure not reproduced here; see the original article.)

As well as being a four-stage cycle for each Round, our findings suggest that each stage has a cumulative impact on the next. Thus, temporally, stage 4 of one Round or a series of Rounds has an impact on the early stages of the next Round or Rounds. This is important, as it takes time to establish Rounds and create resources, for example experienced facilitators, trust and psychological safety, and a ‘Schwartz-savvy’ audience.

Linked cumulative context–mechanism–outcome configurations

To illustrate the cumulative impact of Rounds another way, we present how our nine refined CMO configurations are interlinked (Figure 10). Group interaction, and trust safety and containment, which are both core components of the Schwartz Round model, are prerequisites for all other CMO configurations. Storytelling and self-disclosure share similar theoretical processes (e.g. cognitive integration, making sense of experiences), so they have been grouped together, whereas ‘role-modelling vulnerability’, ‘contextualising patients and staff’ and ‘shining a spotlight on hidden roles’ are all examples of what is being offered and revealed as part of the process of self-disclosure and storytelling. Reflection and resonance is triggered by hearing stories and witnessing the self-disclosure of panellists, and, as audience members also share their stories and self-disclose, this creates cumulative effects for future Rounds.

FIGURE 10 Visual representation of evidence to illustrate how CMO configurations link together to explain how Rounds ‘work’. (Figure not reproduced here; see the original article.)

Ripple effects may occur as ‘unanticipated outcomes’ or ‘side effects’ of Rounds, because part of the countercultural nature of Rounds is that they are explicitly free from the usual expectations around the identification and allocation of tasks, responsibilities, actions and changes that would normally be part of team meetings or similar interventions such as reflective practice or clinical supervision. Ripple effects occur because individuals, or groups of individuals, decide to act on or take forward initiatives outside Rounds as a result of what they have heard. This can be difficult for new attendees to grasp and, because of the prevailing NHS culture, some attendees felt some frustration that there were no action plans or outcomes. Over time participants reported that they came to appreciate the different space provided by Rounds and realised they could take action: just that it was not a requirement. In terms of the countercultural/third space, we suggest that this is driven by fidelity to the model (not problem-solving; safe and confidential space) also outlined in Chapter 7 and is an accumulation of all of the other CMO configurations, thus making the whole Schwartz Round a countercultural and a ‘third space’ (see below for further explanation). Outcomes are either predicted on the basis of theory (i.e. programme or existing relevant theory) (anticipated) or evidenced by data.

Detailed context–mechanism–outcome configurations

We now present each of the nine CMO configurations in detail. We have separated the resource and response in the mechanisms where applicable. Further supporting data for each CMO configuration are presented in Report Supplementary Material 11.

Trust, safety and containment

Our data suggest that key to the successful implementation of Rounds is the concept of trust and safety (Box 5). This is important in all three initial Rounds stages: selecting the story or theme, the panel preparation and the Round itself (see Figure 10). Participants’ feelings of trust, safety and containment develop throughout the stages of a Round and intensify and are reinforced over time, through constant repetition and reinforcement for subsequent Rounds. Safety in Rounds means a space where panellists and audience members feel accepted, respected and valued. Facilitators ensure psychological safety through the use of ground rules including confidentiality and anonymity, through providing non-judgemental support, through the use of the Schwartz model to provide a bounded and established time and through the use of the routine and rituals of Rounds. Conversely, an ‘unsafe’ Round would include panellists and audience members experiencing embarrassment, rejection, reprisal or blame, or experiencing bullying and punishment for speaking out. Thus, in Rounds where safety may have been compromised, this can have a damaging impact on participants’ feelings of trust, safety and containment and, thus, on their willingness to attend, participate and disclose.

We had not fully appreciated the importance of trust and containment as a mechanism in the implementation of Rounds at the beginning of our study, despite ‘safe and non-judgmental space’ being in our original programme theory. However, through our interviews and observation it became clear that in order for people to feel confident to speak, to allow themselves to be vulnerable and to share their stories, emotional safety (held and supported largely by the facilitator/clinical lead), which includes the concept of ‘containment’, allows trust to develop in audience and panel members, thereby facilitating open and honest dialogue. The aim is to allow panellists and attenders to express and explore feelings that may feel too shameful or painful to be shared with others; theory suggests that it is through this process that attenders learn to cope with those damaging, overwhelming or potentially explosive emotions.90

Aspects of safety noted by our panellists, audience members and facilitator interviewees included pre-Round safety checks, such as checking that panellists understand the potential consequences of publicly telling their story and countering the ‘urge to confess’, ground rules on confidentiality stated at the start of every Round, and a signed agreement regarding confidentiality when attenders sign in.

Intermediate outcomes

Our survey data support the outcomes from this CMO configuration, identifying stress reduction (GHQ-12 ‘caseness’) in Rounds attenders versus non-attenders (see Chapter 5). In interviews, staff reported that the safe, confidential space provided by Rounds enabled them to be better practitioners, to think about their behaviour, to make different future choices and to be more empathic with patients, for example:

[Rounds are] a safe space to discuss things that are challenging [. . .] this enables practitioners to be better practitioners and be more empathic, have a moment to stop and think about themselves and their behaviours and others’ behaviours, and that reflection may help [. . .] in the future.

Our data support other work that suggests that some mechanisms operate on a continuum, like a ‘dimmer switch’, rather than simply the mechanism ‘firing’ or ‘not firing’.91 Contextual factors that turn up this mechanism’s dimmer switch include the extent of panel preparation, the facilitator’s skill and/or experience, and the audience’s Schwartz savviness (see Chapter 7).

Theory suggests that containment provides a sense of safety for the panellist and audience members to explore feelings that may otherwise be experienced as overwhelming and confusing. It is often about ‘holding’ the alarm, confusion and pain of unfamiliar or overwhelming feelings, and can be described as the capacity of one person to stay with, and psychologically and emotionally hold, the distress of another person in such a way as to allow it to be coped with.92 It requires the facilitator to manage their own sense of uncertainty and confusion in order to be effective in helping those in Rounds to manage their own feelings. The facilitator needs to provide the confidence and presence to enable panellists and Rounds attenders to believe that their difficult feelings can be managed, explored and understood to avoid unsatisfactory coping mechanisms.93 Confidentiality is crucial if members are to take risks necessary for real growth;37 our data provided evidence to support these theories:

It’s set up to be a safe, confidential forum [. . .] I mean often it’s come to my mind about using a psychotherapy term of ‘containment’ but a place for people to express their feelings, some containment both from the panel and other people in the audience, to understand the emotional reaction to it, for it to be OK to express feelings that might seem strange, unacceptable, awful. [. . .] some understanding about why people are feeling that way

Group interaction

This CMO configuration (Box 6) primarily relates to the Round itself (i.e. stage 3) and only relates to some panel preparation meetings (stage 2), as some are conducted one to one and not in a group. Our initial programme theory identified that it was important to have a range of attendees in a multidisciplinary group of health-care staff but did not identify which aspects of this would be an important mechanism.

Our data analysis has unpacked this mechanism further, highlighting the importance of sharing stories and reflecting as a group activity. Reflection can often be an individual introspective process with little insight into the similar experiences of others. Rounds as a group process of interaction provide an opportunity to trigger reflection in others through hearing stories and hearing others ‘reflect on action’, triggering resonance and reflection in individuals. Individuals are able to achieve higher levels of learning and retain more information when they work in a group rather than individually.94

The experience of listening to the stories of others and sharing stories underpins Rounds, creating a group intervention in which staff can feel heard and supported, and are exposed to the experiences of others. This gives the potential for Rounds to be a ‘richer’ intervention than one-to-one reflective sessions or supervision, and we suggest that the group interaction element of Rounds is an important prerequisite for other CMO configurations. Drawing on theory, we identified six factors that add to the experiences of Rounds participants because it is a group intervention: (1) cohesiveness, (2) universality, (3) shared values and motivation, (4) catharsis, (5) interpersonal learning and (6) self-understanding.37 Being in a group can help participants learn factual information from others and how to share personal feelings, show concern, and support others through a modelling process, observing and imitating the facilitator, clinical lead, panellist and audience.37

The resources offered by Rounds being a group intervention included the recognition of shared experiences and feelings (reaction); insights into others’ experiences and how they connect everyone; and the acknowledgement of the contribution and work of less visible, non-clinical staff. Interviewees identified the importance of the multidisciplinarity of the group, the flattened hierarchy and the opportunity to think and learn from each other (see Report Supplementary Material 11 for more supporting data):

I think the very big difference [between Rounds and one-to-one supervision] is, particularly in a big organisation like this, is that there is no other forum that’s multidisciplinary and there is no other forum where no matter where you are in the staff hierarchy you are empowered, if you wish to take it, to have a voice, I think that’s the hugest difference.

All in it together and it’s kind of ‘oh I didn’t know it was like that for you’. I think it strengthens the connections and the relationships with other people [. . .] it’s this kind of shared experience around challenges, making change or dealing with loss or feeling stressed by your work, whatever it might be.

Countercultural/third space for staff

The countercultural and third-space mechanism of Rounds was not explicitly in our original programme theory, but our data and recent literature shifted our thinking. In late 2016, a book by the former lead mentor for Rounds in the UK, Barbara Wren, was published in which she wrote: ‘the process of Schwartz Round implementation is in many ways counter-cultural. Good Rounds shift an organisation and its workers away from their default position of urgent action, reaction and problem solving to an hour of stillness and slowness’ (p. 41).95 Our data supported this and helped us to identify the countercultural nature of Rounds as a key mechanism: albeit as a group-level mechanism. The countercultural/third-space environment is a mechanism but also over time becomes the resource and context for the other CMO configurations, as outlined above: storytelling and self-disclosure and reflection and resonance sit within this third space (see Figure 10). The third space is a resource provided/offered and co-created by participants to enable other mechanisms to ‘fire’ (Box 7).

We drew on and tested our findings regarding Rounds being a countercultural space in relation to third-space theory. First and second spaces are two different spatial groupings where people interact physically and socially, such as home (everyday knowledge) and school (academic knowledge). Third spaces are the in-between, or hybrid, spaces, where the first and second spaces work together to generate a new third space96,97 to create a hybrid culture and identity because respite is needed from any challenges to functioning in the second space.96,98

We identified nine aspects of ‘third space’ in the literature98 and tested if these ‘fitted’ well with Schwartz Rounds in focus group interviews with mentors. Participants agreed with items 1–6, and less so with items 7–9:

1. free – third spaces also generally offer food and drink, the staples of socialising
2. neutral ground
3. leveller
4. conversation is the main activity
5. easy to access and accommodating
6. cadre of regulars
7. low profile*
8. playful*
9. home away from home.*

Items marked by asterisks were felt by some not to fit so well with Rounds, but one facilitator felt that Rounds were low profile in that by their countercultural nature they could be ‘under the radar’ of the organisation’; and that they could at times be fun and playful, and certainly that a ‘home away from home’ atmosphere was strived for, although it was recognised that this was different from the examples in the literature, such as coffee shops.

One aspect that does relate to other third spaces such as coffee shops is the provision of food (which is in the PoCF contract, is symbolic of community and ‘breaking bread together’, and is also somewhat countercultural). Our data suggest that Rounds are third spaces where staff can connect with their values and humanity, with the first and second spaces being (1) professional/role identification and values (everyday work) and (2) NHS/organisation (imposed work practices) spaces.99 Third space offered four applications for our work on Rounds:

1. recognised space, in which professionals could ‘hang the confusion and chaos’99 of the workplace for a time while they thought through their practice100
2. community space, creating a community of commitment101 and a community of creation102 not centred around targets, objectives and rational negotiations about how goals can be achieved, but on ‘what people care about and want’ to create together103
3. conversational space, for dialogue between participants that is safe, secure and supportive, space that ‘stands in between’ the formal areas of practice104
4. learning space –

places of transition, and sometimes transformation, where the individual experiences some kind of shift or reorientation in their life world [. . .] [where] a shift in identity or role perception [occurs] so that issues and concerns are seen and heard in new and different ways.

Wren95 suggests that:

by keeping connected to the three overlapping contexts of the patient, the staff member and the organisation, without a requirement to produce an outcome for any of them, Rounds can create a space within which the triangulation of healthcare experience can be both noticed and resisted.

For example:

It would be the factors from the reflections on the Rounds for me [. . .], the reflection that we do as a team on our practice [. . .] just helping me to be better at being compassionate and understanding and open to people recognising the impact on ourselves emotionally. And just that greater resilience.

Others suggested that there had been wider cultural changes (‘ripple’ effects) through changed conversations in organisations, which had been facilitated by the countercultural third space offered by Rounds:

It’s sort of softened the ground for things to grow, the kind of conversations that [a colleague] has with the medics and the different clinicians that are very different to the ones that she was having about a year ago [. . .]. The actual human effect, the empathetic affect of what happens when you’re caring for staff.

Staff spoke about ‘leaving things at the door’ and being in a different ‘zone’ that provided a headspace to reflect. This creates behaviour change by providing an opportunity to do things differently; the honesty, without judgement or fear of any backlash, that was provided in this space was the power of Rounds:

To hear doctors being very honest about a difficult patient and how they handled it. I’d never heard this in this building and I’ve been around 49 years and it was the honesty of it without judgement and I think that was the powerful thing that got to me.

Uncluttered headspace to a certain extent, communal headspace as well, where people can take that hour where you can put the brakes on, you can stop, you can leave that constant drive for performance targets at the door and have that clarity where you can just breathe and start thinking with like-minded colleagues who experience the same pressures where we’re at, where the difficulties are and, kind of, reflect on those [. . .] being able to sit with the emotion, be with the emotion, that you normally just press, push it down, push it down, push it down, move to the next task, [. . .] so, that ability to reflect on your practice and have that headspace I guess when you walking out of the Round and you go back to your clinical practice, that’s where that opportunity to do things differently comes from.

Rounds provided a confidential space that was counter to the prevailing culture in health-care organisations in the following ways:

• flattened hierarchy
• staff experience valued
• emotional disclosure encouraged
• stillness
• resisting outcomes
• revealing and discussing own emotional needs and vulnerability (vs. the myth that this is undesirable for health-care professionals or a sign of weakness)
• support and listen to each other without judgement
• attending to own emotional needs rather than those of patients
• slow reflective space with some silence (see Report Supplementary Material 11 for supporting data).

This resulted in staff being able to be honest, and in revealing emotions being more culturally acceptable.

Self-disclosure

Self-disclosure is the process of sharing information about yourself with another person (or people). Disclosing the human aspects of staff’s work – the social, emotional and ethical issues that they face in their professional lives – is a key element of Rounds. Self-disclosure was part of our original programme theory, but our data shed light on the ways in which it is a key Schwartz mechanism: as part of sharing stories and prompting others to reflect and self-disclose, allowing stronger relationships and trust to develop (Box 8).

Psychological theory suggests that emotional self-disclosure makes individuals ‘transparent’ and vulnerable to others.106 The greater the depth of the discussions, the more likely the person is to feel vulnerable. Therefore, trust built over time among the disclosers (often a panellist or an audience member) and the facilitator/audience is essential to reach deep discussion.

Social penetration theory proposes that, as relationships develop, interpersonal communication moves from relatively shallow, superficial levels to deeper, more familiar ones.107 Disclosure reciprocity is when a panellist reveals personal information of a certain intimacy level, and another panellist or audience member will in turn disclose information of the same intimacy level, creating a sense of emotional equity.108 Disclosure is particularly beneficial in helping people come to terms with chaotic and unexplained events. Empirical evidence suggests that ‘opening up’ and expressing stress-related thoughts and feelings is associated with improved physical and mental health.44 Theory also suggests that sharing fears and problems (as well as good news) with others who are trustworthy and supportive plays a key role in mental health109 and can reduce stress.110 After mutual self-disclosures (as in Rounds) people can feel a boost in positive feelings111 and build relationships with friends and coworkers,112 and emotional, not factual self-disclosures can lead to closeness as long as disclosers feel that listeners are understanding and accepting,113 which links to the importance of good preparation and to the CMO of trust, emotional safety and containment, described earlier in the report.

In sharing information about themselves, people make choices about what to share and with whom to share it. Our data suggest that coming to a different ‘third space’ (see Countercultural/third space for staff) allows people to share and self-disclose in ways that they would not elsewhere, so that they come into the room as a person and not only as a professional. Some suggest that this enables barriers to come down and allows them to ‘share from the heart’:

Outside of Schwartz Rounds people tend not to share as much, for whatever reason [. . .] it’s often the most junior members of staff that set the ball rolling with deep sharing, such as the health-care assistants for example. They share from the heart and I just wonder whether it’s the actual humanity where you’ve taken your professional badge or hat off, metaphorically speaking obviously, that you come in as a person and I think the subject themes guide that in many ways because it allows you just to be vulnerable, to share about a time or an experience in your life and I just think that really just maybe energises others to feel safe [. . .] I think we just connect with that human sense of caring [. . .] and I think it’s maybe that it just pulls down so many barriers that people and I think [. . .] there’s some connection or some energy I think that it generates in the room.

An outcome of this is connecting staff back to their own humanity and the ‘human sense of caring’, connecting staff together by ‘pulling down so many barriers’, revealing the person in the professional and connecting staff to their empathy and compassion for self and others (staff, patients and carers). Emotional self-disclosure makes individuals ‘transparent’ and vulnerable to others. The greater the depth of the discussions, the more likely participants are to feel vulnerable. Trust built over time is essential to reach the deep discussion and to provide some catharsis:

And I think it’s often that cascade where people just feel safe. I suppose going to a lovely gathering with people that you feel really comfortable with and you have a good old laugh. That cathartic sense of being together or a cry or a row or whatever it is, but it feels safe to do that and you can recollect and it, the connection and the bond are still there.

Participants reported that the audience response and acceptance is validating, with a supportive audience helping panellists reframe and see an experience they have ‘held’ for a long time more positively and so make it less stressful and emotionally challenging for them (see Report Supplementary Material 11). A panellist who had been assaulted by a patient reflected:

We started talking about how the patient must have felt, how frightened he must have been [. . .] and I’ve never really had that kind of thoughts about what it would have been like for him [. . .] and [now] that anger has largely gone actually and I felt much more connected to his distress and I was able to get through that anger and, to a certain extent, that hatred for him [. . .] hate is a very, very strong word but if you are insulted or hit or assaulted by a patient sometimes hate is an emotion that it can instil within.

Storytelling

Telling a powerful Round story starts with an initial idea for a generic theme (e.g. ‘a patient I’ll never forget’), or a wider organisational incident, event or issue (e.g. ‘the junior doctors’ strike’), or a particular case, team or individual (e.g. ‘making a conscious decision to die’). The mechanism of crafting and telling a powerful story that resonates with others was not initially in our programme theory, yet as we began our interviews and observations we were struck again and again by how moved we were by the stories we heard, how they resonated with us and how so many people spoke of the ‘power of the story’. Storytelling and stories as a trigger for reflection are central to Rounds and therefore emerged as a key element of our revised programme theory (Box 9). Wren95 writes that ‘the story is the engine’ (p. 43) and highlights the importance of the ‘use of story to reveal experience in a prepared and crafted way, which allows the audience to move closer to a positive experience of managed exposure and a gradual acceptance of incompleteness and unfinished business’ (p. 43).

Stories are vehicles for behaviour change and can have longer-term outcomes/ripple effects, such as changes in practice, including changes to resuscitation protocols, and long-term benefits for staff well-being:

It has led to some additional work being done [. . .] In one case it led to the review of a particular protocol. [. . .] We had one particular Round, which was around ‘do not resuscitate’, and I know that that fed into more work being done around procedures and protocols around resuscitation. So, very often, it will feed into the current debates in the trust around whether it’s resuscitation or end-of-life care or, drug safety or whatever.

A colleague e-mailed her boss to say, ‘I have attended a Schwartz Round, don’t you think it’s a good idea if we reintroduce clinical supervision in our practice?’ And, indeed, they reintroduced it, purely because they heard the stories of people going through something, and perhaps they should change. She said, ‘Just to let you know, we’re back to doing this in nursing because of hearing the Schwartz Round,’ so you know, I have a direct example of people actually proactively changing something.

Other data, detailing outcomes such as support and affirmation, a sense of closure for staff, an opportunity to discuss previously unsaid things leading to some resolution and (positive) impact on teamwork, can be found in Report Supplementary Material 11.

Stories are an effective way to transmit important information and values from one individual or community to the next. Personal and emotionally compelling stories engage more of the brain and are better remembered than simply stating a set of facts, and theory suggests that stories are ‘empathy workhorses’.114 An effective story captures and holds attention and transports us into the character’s world. ‘Transporting’ is the ‘magic’ that happens when a story holds full emotional and mental attention; we experienced this often in Rounds observation when it felt like everyone in the room was holding their breath and it would have been possible to ‘hear a pin drop’. An example was an organisation’s first Round that was called ‘too young to die’:

We had a really good attendance, we had four panellists who were all really good and had a massive impact. I’m sure you have, but have you ever been in a room where it just goes totally silent? [. . .] And you can feel it? [. . .] We had that [. . .] people talked about it for months after [. . .] we had a wide range of panellists [. . .] and they all told a different story, but really, really, really strong stories, it was brilliant.

Good stories (‘Schwartz gold’) spark and engage through emotions and connect people. Stories were crafted in panel preparation to resonate, ‘paint pictures’ and transport listeners to a scene:

I relived it in my head so I could still remember the person’s room as I was sharing it and although I was picking up eye contact with the audience and kind of, I was kind of back in that person’s room. And even I could hear the clock ticking that he had on his sideboard. I could still hear that when I was passing that onto the audience. Yeah it took me back there and it brought it alive again.

Our data suggested that the trigger stories were key to Rounds’ success. Respondents seemed to locate the essence of the Round in the emotional experience of the creation of a powerful, positive or rewarding embodied experience for them:

Powerful to be honest, very different stories and I think I don’t know that I was prepared for the outward emotion from the storytellers [. . .] actually witnessing that for real and it’s reliving it even though it was some time ago, you know, that whole outpouring of emotion was quite powerful. And [. . .] it’s the variation in the stories were massive actually. You’ve got clinical director right through to a health-care assistant that’s holding someone’s hand.

When stories ‘transport’, they generate empathy and the brain produces oxytocin, which, when synthesised, makes people more trustworthy, generous, charitable and compassionate, and more sensitive to social cues around them.114 Stories were important vehicles for reflection:

It was very powerful hearing other people’s stories [it] makes you think about your own practice and how you deliver the care that you deliver [. . .] as well as the bigger picture.

Role-modelling vulnerability

As outlined in Figure 10, ‘role-modelling vulnerability’ is an important aspect of ‘self-disclosure’ and of the countercultural/third space. Revealing, and specifically role modelling, vulnerability is unusual for health-care staff, who rarely show vulnerability in their daily work, and instead display confidence, certainty and invincibility so that they reassure patients and facilitate patients’ confidence in them. Role-modelling vulnerability was identified in our original programme theory, and our data reveal why this aspect is important in how Rounds may ‘work’ (Box 10).

Vulnerability facilitates human connection through the willingness to be present and let ourselves be seen, yet shame gets in the way of authenticity as people become paralysed with fear about what others might see.115 In health care, Tomlinson116 suggests that public shame and humiliation on ward rounds in medical education gets in the way of honesty or openness for fear of making a mistake or being ridiculed. Brown115 suggests that vulnerability is not a weakness, but it is an emotional risk, and it is the most accurate measurement of courage; shame inhibits connection with others, with people fearful that they are not worthy of it. Being vulnerable allows Rounds participants to connect at the level of their humanity with each other, not as professionals but as fellow human beings. It also demonstrates courage and empowers others to be authentic and vulnerable, creating a circle of connection and allowing staff to be more honest, open and empathetic with each other. Brown117 suggests that shame cannot survive empathy or being spoken about, and that talking about shame ’cuts it off at the knees’ (p. 58117). Our data suggest that good facilitation (supporting emotional safety) can prevent vulnerability turning to shame.

Witnessing peers role modelling courage and bravery creates a level playing field, which breaks down barriers between staff groups and is empowering for others. The language of vulnerability revealed much about how health-care professionals cope in their daily work. Our interviewees spoke of ‘masks’, ‘armour’ and ‘protective shells’ being removed:

It’s interesting to break down some of those barriers of the façade of the consultant, the façade of the surgeon, the façade of the bed manager and actually get to the human being behind the role, because I think that that really puts us on a level which I think is a very healthy place to be [. . .] think that that’s a real leveler within a working environment in a very healthy way [. . .] it’s also a very helpful thing to see the human being behind the mask, so to speak.

You are allowed to be a human being and to be vulnerable, and I guess that’s what we were all doing at Schwartz. We were all showing our vulnerability in different ways and . . . being honest about that and not trying to pretend that this stuff doesn’t have an impact, ‘cause it does.

The revealing of vulnerability by senior staff in particular was felt to reduce feelings of isolation, and to be empowering, encouraging and supportive to other staff (see Report Supplementary Material 11 for more supporting data).

Contextualising patients and staff

‘Contextualising patients and staff’ is an important aspect of ‘storytelling’ and ‘self-disclosure’ (see Figure 10); it was not in our original programme theory, but we suggest that this CMO illuminates how staff ‘support and teach each other how to better connect with patients (and each other)’ (Boxes 11 and 12). As a result of panellists’ willingness to self-disclose, show their vulnerability and tell their story publicly, audience members and fellow panellists gain an expanded knowledge of patients and staff. They hear multiple perspectives about the same patient from different colleagues, and hear more about the external and contextual factors that impinge on individual patients’ and staff’s decision-making and behaviour. This also gives staff a longitudinal, rather than cross-sectional, perspective of what happened to a patient, which can be particularly important for junior staff/students and colleagues who were involved in one part of a particular patient’s care. In short, they are able ‘to put themselves in the patient’s shoes’ or get a ‘glimpse into the everyday world of that individual staff member’.

Our observation of Rounds provided data to support these insights. For example, after hearing experienced and expert panellist colleagues’ insights into why a patient infected with HIV (human immunodeficiency virus) had not disclosed this to her partner, the initial judgments from a junior colleague changed to a compassionate understanding of the woman’s circumstances and situation, and awe at colleagues’ ability to support the woman to subsequently disclose in a safe way.

Theoretically, the fundamental attribution error supports our understanding of this CMO. Fundamental attribution error is the tendency to explain someone’s behaviour based on internal factors (personality or disposition) while underestimating the influence that external and situational factors and influences have.118,119 Rounds remind people that others’ behaviour is constrained by situational factors and present an opportunity to take into account behavioural and situational information simultaneously to characterise the actors (patients, carers and staff). Our data suggest that fundamental attribution error applies to contextualising both patients and staff, and we provide separate CMOs for (1) patients and (2) staff.

Interviewees spoke of Rounds providing greater context for their patients’ lives and facilitated greater insight into people’s behaviour, changing perspectives:

I think it’s enabled ‘difficult patients’ or difficult cases to be understood and digested in a more constructive way, in a less defensive way, in a more reflective way. [. . .] but I do think [. . .] that it’s helped people understand the more complex and more challenging cases and why people behave like they do.

Well it’s certainly changed the way I view patients [. . .] I think I’m much more aware of their back story, if that makes sense.

This allowed staff to step back from challenging and distressing incidents and to ‘walk’ in their patients’ shoes, thereby fostering empathy and changing behaviour:

It makes us think about what we’re doing and we’re walking in their shoes a bit more. I think also you reflect on and you internalise what you’ve heard so even subconsciously you think ‘I might try or do that a bit differently’.

Interviewees spoke movingly of the insights Rounds gave them into colleagues’ worlds and behaviours through the telling of honest, open and powerful stories in which staff revealed their vulnerability; this resulted in attendees feeling more generous towards colleagues and themselves, and having greater tolerance and empathy, resulting in compassion and greater trust (see Report Supplementary Material 11 for further data):

You’re much more sympathetic and tolerant of the decisions other people make [. . .] Rounds are really helpful in reminding [us] that everybody is trying to do their best. [. . .] a more generous understanding of other peoples’ difficulties and how hard everybody is trying [. . .] which makes it easier to be generous to ourselves then as well, in the sense of acknowledging that we do a really hard job.

Hearing more about what the challenges are for us all in our different professions, I think is a useful [. . .] it does make us more tolerant towards each other.

Shining a spotlight on hidden stories and roles

‘Shining a spotlight on hidden stories and roles’ is an important aspect of ‘storytelling’ (see Figure 10), but was not in our original programme theory. We suggest that it illuminates how staff ‘support and teach each other how to better connect with patients (and each other)’ through providing staff with greater insight and understanding of what people’s roles involve, enabling them to learn from each other, foster mutual respect and value a wider range of staff/colleagues, strengthening relationships with other staff, team relationships and spirit (Box 13).

Our data supported the theory that suggests that Rounds enable less visible roles to be made visible, enabling work perceived as routine to be reframed so that what might be seen as background work with low status can potentially be elevated in care work terms.120 Our data suggested that attendees gained powerful insights into the roles of others, realising that all staff are affected by the challenges of patient care and experience difficult emotional responses. This enables attendees to create and sustain different notions of what the work is and of the person doing the work, because part of the identity-shaping process in ‘job crafting’ is relational.121 This also enables some staff to connect with the ‘bigger project’ and the purpose of the organisation (caring for and helping patients recover or die well) to others and their values, and reinforces their own values.

By ‘shining a light on hidden roles’, staff reported connecting with each other and feeling less isolated, and we were provided with a concrete ripple effect of staff meeting up who had not done so before (connecting people and reducing isolation):

But in our last Round, we brought a person from A&E [accident and emergency] and a person from the hospital co-ordinator side, and a person from mortuary [. . .] They were talking as if they were on separate planets, not one person knew what the other person was going through, at the very same time, but it was the exact same event [. . .] afterwards, [. . .] I saw them in the corridor and they said, they’ve invited each other for cups of tea, if they’re in in the evening, because they’re all there in the hospital, feeling very isolated [. . .] so these departments are now meeting up for cups of tea every now and then in evening, on the power of realising that, [they felt] isolated that day [. . .] just people realising that they’re not alone, which to me, is a very good impact.

Interviewees spoke of Rounds stories presented by staff they rarely encountered providing new ‘windows into other people’s worlds’, making visible invisible work/workers and giving greater insights into the organisation, allowing staff to feel part of a bigger ‘jigsaw’:

I’ve learnt a great deal about what other colleagues do, but also [. . .] how they see their working worlds [. . .] it’s those windows into other people’s worlds [. . .] for example there’ve been some amazing things that some housekeeping people and facilities have talked about that certainly other people didn’t realise and I didn’t realise [. . .] And then at the other end of the professional spectrum [. . .] the experience of more senior doctors, the consultants, having that ultimate clinical responsibility, and having to give the impression of being sure and confident when actually they feel anything else but that, the weight of that responsibility.

Those whose roles and hidden stories were ‘spotlighted’ spoke of feeling appreciated, supported and valued for their work. Interviewees also spoke of the link between personal stories of health care and organisational life: linking these; making staff visible; shining a spotlight being an exercise in enhancing teamwork; having the opportunity to meet new people at Rounds and put names to faces; and helping staff appreciate and know about each other’s roles much more, resulting in greater understanding and appreciation of their work (see Report Supplementary Material 11 for more supporting data).

Reflection and resonance

Reflection and resonance (situated within the third space CMO; see Figure 10) is triggered as the result of hearing stories and witnessing the self-disclosure of panellists, and as audience members also share their stories and self-disclose, this creates a resource for others (Box 14).

Reflection was in our original programme theory and is the vehicle through which staff make sense of their own and others’ experiences. Resonance was not identified in the original programme theory; however, our data suggest that when the story or experience resonates, reflection is triggered, which can ‘strengthen the carer/patient relationship by providing space to reflect on the cost and impact of caring’ (p. 39).95 Reflective practice is the process of learning through and from experience to gain new insights of self and/or practice through examining assumptions of everyday practice, being self-aware and critically evaluating their own responses to practice situations.53,122–124 ‘Reflective practices offer us a way of trying to make sense of the uncertainty in our workplaces and the courage to work competently and ethically at the edge of order and chaos’ (p. 7),125 which resonated with our Rounds data.

Longer-term outcomes and ripple effects included improvements in patient care through recognising the importance of staff well-being and its direct connection to patient care. By sharing and learning from one’s own and others’ mistakes, care can be improved in the future, by embedding a culture of reflection and Rounds that results in recognition of nurses needing more support, leading to a reintroduction of clinical supervision:

Sometimes people do talk about their mistakes and [. . .] that by talking about these things we improve care. [. . .] ultimately one of the cases we can make for why you must continue to fund them is actually well-being for staff, if we’re going to directly impact on helping the patients [. . .] via self-well-being it would improve patient care [. . .] are we well enough to do good patient work?

Rounds were identified as an important, safe space to offload, think creatively and be challenged, and through this process staff learnt to think back on previous experiences, learn from each other and apply that learning in future encounters with patients:

In terms of my relationships with patients it’s been very helpful to have some time for reflection and I think maybe I would like to think [. . .] that I might try and react differently and try a different approach, whether it be just standing up, leaving the room and shutting the door which I think might be what I try next time and seeing what effect that has.

Many staff suggested that this was the only opportunity for them to have a safe space to reflect and think about ‘tacit knowledge’ in a safe space, which provides a resource to share knowledge and, through that process, has an impact on the practitioner and improves patient care:

I think one of the biggest impacts is [. . .] on the quality of people, patient’s experience [. . .] that space to kind of reflect in a safe space away from the coalface of what is happening, surely has an impact on how good a practitioner someone is [. . .] it gives them a little bit of space to kind of have their reflection in a way which is well structured. Whereas many of us, you know, don’t have any of those things and [. . .] it’s one of the very few learning interventions which has that kind of effect of helping people really gather up and pause and think about actually that tacit knowledge which you don’t get from anywhere else other than those conversations.

Interviewees suggested several ways in which this happened: (1) through validating the work they do (we repeatedly heard staff suggesting that what they did ‘was just part of the job’ and ‘not extraordinary’, whereas their colleagues were often humbled and in awe of their practice, validating and supporting through their feedback); (2) through recognising that their experiences and feelings were not unique, and that by talking about their experiences, rather than internalising them, realising that their experiences are shared and are a normal part of the job, which reduces feelings of isolation; and (3) through reflection, allowing them a pause from the busy environment of care work (in a countercultural space), which enables them to be less reactive (see Report Supplementary Material 11 for supporting data).

Summary

We have identified nine CMOs, which are cumulative and interconnected. Together with Chapter 7, this provides insights into what works, for whom and in what circumstances. We have used these data to refine our initial programme theory and to develop our evidence-informed programme theory.