NIHR Signal A reflective group activity supports healthcare staff in England
Published on 5 February 2019
Regular participation in structured organisation-wide forums, known as Schwartz Center Rounds®, helps support healthcare staff. The forums are linked with increased empathy and compassion for colleagues and patients, and they facilitate practice change. Levels of poor psychological well-being decrease in forum attendees compared with non-attendees.
Originating in the US, these forums provide the opportunity for clinical and non-clinical staff, from Chief Executives to porters, to deliver enhanced compassionate care by gaining insight into their thoughts, feelings and behaviours while reflecting and telling stories about their interactions and experiences with patients in a safe setting.
This NIHR-funded evaluation is the first mixed-methods, large-scale evaluation of the forums in England. They are now more widely adopted in the health service. The evaluation identifies learning and practical tips on running these forums well which could be useful for other organisations.
- Commissioning, Health management, Public and patient involvement, Primary care, Acute and general medicine
Why was this study needed?
Investigating the poor care and high mortality rates of patients at Stafford Hospital, England in the late 2000s, the Francis Report called for every NHS employee to contribute to a safer and more compassionate service. The Care Quality Commission acknowledges that staff wellbeing is associated with the quality of patient care, though the latest NHS Staff Survey (2017) states that in the past year 38.4% of staff felt unwell due to work-related stress.
Schwartz Centre Rounds® provide a reflective practice forum for staff to focus on relational aspects of care to give staff insight into the roles of others ad decrease feelings of stress and isolation. Forums typically have four cyclical stages: sourcing stories and panellists; crafting and rehearsing stories; telling stories to trigger reflection and resonance; post-forum ripple effect into the organisation.
Originating in the US, forums are growing in popularity in the UK. This research aimed to clarify which factors contribute to successful implementation in what contexts and for whom.
What did this study do?
Phase one of this mixed methods evaluation mapped 115 health organisations - Acute/Ambulance/Community/Learning Disability Trusts and hospices - in England who were already using forums. A scoping review appraised 10 papers exploring facilitators of successful forums and compared them to 146 papers describing 11 alternative interventions.
In phase two, looking at mental health wellbeing, health surveys were collated from 1,140/3,815 staff across 10 organisations at baseline (30% response rate), and 500/1,140 staff at 8-month follow-up (44% response rate) thought to be reasonable response rates in these settings. Observations of 42 forums, 29-panel preparations and 28 steering group meetings, and 177 interviews were conducted with forum members from nine organisations. They explored: how forums operate; mechanisms for measuring effects; experiences of attending/presenting; topics discussed; facilitation and wider organisational effects.
This study provides a rounded insight into the factors which facilitate successful forums in England and the context of their success.
What did it find?
- Psychological well-being scores improved significantly in regular forum attendees between baseline and eight months. According to the General Health Questionnaire-12, the proportion who scored more than 3 (scale 0 to 12 with scores above 3 indicating mental distress) dropped from 25% to 12% in attendees compared to from 37% to 34% with non-attenders (odds ratio 0.66, 95% confidence interval 0.43 to 0.99).
- Four core components and four adaptable components were identified as being key to success. Essential core components are senior clinical leadership; facilitator-led; group participation; availability of food. Adaptable components which can be modified according to the structures and systems of the organisation are number of panellists, e.g. 2-4 panellists; scale, e.g. single vs multiple organisations; regularity, e.g. more or less than once a month; and type of forum, e.g. teleconferencing or video conferencing.
- Attendees reported a better understanding of colleague, patient and carer behaviours, increased empathy, closer teamwork and improved communication.
- The impact of forums can be cumulative as attendees understanding of the purpose of forums grows and their ability to contribute increases.
- Attendance can be problematic for those with limited autonomy over their workload or where attending the forum conflicts with other clinical priorities.
What does current guidance say on this issue?
Currently being updated, NICE 2009 guidelines recommend the adoption of organisation wide approaches to promote the mental wellbeing of all employees.
What are the implications?
This evaluation provides practical advice on how the aspirations of NICE guidelines in facilitating organisation wide approaches to promoting employee mental wellbeing can be implemented in hospitals.
Although the adoption of healthcare staff forums is spreading, this evaluation highlights some critical conditions for these to work well. This includes organisations encouraging and facilitating attendance for staff who have limited workplace autonomy or demanding workloads.
This evaluation will be of interest to members of senior clinical leadership teams who are highlighted as a core component in the success of healthcare staff forums.
Citation and Funding
Maben J, Taylor C, Dawson J et al. A realist informed mixed-methods evaluation of Schwartz Center Rounds® in England. Health Ser Del Res. 2018;6(37).
This project was funded by the National Institute for Health Research Health Services and Delivery programme (project number 13/07/49).
Maben J, Leamy M, Taylor C et al. An organisational guide: understanding, implementing and sustaining Schwartz Rounds®. London: Kings College London; 2018.
NICE. Mental wellbeing at work. PH22. London: National Institute for Health and Care Excellence; 2009.
Taylor C, Xyrichis A, Leamy MC et al. Can Schwartz Center Rounds support healthcare staff with emotional challenges at work, and how do they compare with other interventions aimed at providing similar support? A systematic review and scoping reviews. Health Services Research. 2018;8(10).
The King’s Fund. Schwartz Center Rounds. London: The King’s Fund; 2019.
The Point of Care Foundation. About Schwartz Rounds. London: The Point of Care Foundation; 2019.
Working in healthcare can be demanding and stressful. Schwartz Rounds® offer a forum for clinical and non-clinical teams to share personal stories and discuss the emotional impact of delivering healthcare.
Over time, participating in these sessions help staff feel less stressed and isolated at work and more empathetic when dealing with patients and colleagues, providing further evidence for the link between staff wellbeing and positive patient outcomes.
This study also identified the factors that make forums effective for teams working in acute and non-acute settings. Forums represent one of the few evidence-based interventions that work at both an organisational and person-centred level.
Dr Helen Allbutt, Principal Lead, NHS Education for Scotland
The commentator declares no conflicting interests.
The evaluation provides a comprehensive review of the purpose, value and implementation challenges of Schwartz Rounds® in the UK.
For executives who are considering how to support staff working in health care, this evaluation enables them to make an informed decision about whether rounds are an appropriate intervention and the requirements to run them.
With a clear explanation of the evidence base behind how rounds work and the potential pitfalls, this extensive piece of research offers an invaluable insight into how to give rounds the best chance of success. I would fully recommend a read.
Rebecca Myers, Organisational Development Practitioner; Visiting Fellow - School of Health and Social Care London Southbank University
The commentator was involved in the piloting of the Rounds in the UK as an Executive Director in one of the pilot's sites in 2009. The commentator introduced Rounds to another Trust in 2014 and has been a co-facilitator of the Rounds since their introduction.