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A realist informed mixed-methods evaluation of Schwartz Center Rounds® in England

Health Services and Delivery Research, No. 6.37

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Author Information
Southampton (UK): NIHR Journals Library; .


Schwartz Rounds offer a unique form of support, and although implementation varies and challenges include resourcing and accessibility, Rounds can improve well-being, increase empathy for patients and colleagues and change practice.



Schwartz Center Rounds® (Rounds) were introduced into the UK in 2009 to support health-care staff to deliver compassionate care, something the Francis report (Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office; 2013) identified as lacking. Rounds are organisation-wide forums that prompt reflection and discussion of the emotional, social and ethical challenges of health-care work, with the aim of improving staff well-being and patient care.


How, in which contexts and for whom Rounds participation affects staff well-being at work, increases social support for staff and improves patient care.


(1) A scoping review of Rounds literature and comparison with alternative interventions; (2) mapping Rounds providers via a survey, telephone interviews and secondary data; (3) a two-wave survey of (i) new attenders/non-attenders in 10 sites to determine the impact on staff engagement and well-being; and (ii) interviews with Rounds attenders, non-attenders, facilitators, clinical leads, steering group members, board members and observations in nine case study sites to (4) describe experiences and (5) test candidate programme theories by which Rounds ‘work’ (realist evaluation).


(1) International literature (English); (2) all Rounds providers (acute/community NHS trusts and hospices) at 1 September 2014 (survey/interview) and 15 July 2015 (secondary data); (3) 10 survey sites; and (4 and 5) nine organisational case study sites (six of which also took part in the survey).


(1) Ten papers were reviewed for Rounds and 146 were reviewed for alternative interventions. (2) Surveys were received from 41 out of 76 (54%) providers and interviews were conducted with 45 out of 76 (59%) providers. (3) Surveys were received from 1140 out of 3815 (30%) individuals at baseline and from 500 out of 1140 (44%) individuals at follow-up. (4 and 5) A total of 177 interviews were conducted, as were observations of 42 Rounds, 29 panel preparations and 28 steering group meetings.


(1) The evidence base is limited; compared with 11 alternative interventions, Rounds offer a unique organisation-wide ‘all staff’ forum in which disclosure/contribution is not essential. (2) Implementation rapidly increased between 2013 and 2015; Rounds were implemented variably; challenges included ward staff attendance and the workload and resources required to sustain Rounds; and costs were widely variable. (3) There was no change in engagement, but poor psychological well-being (12-item General Health Questionnaire) reduced significantly (p < 0.05) in Rounds attenders (25% to 12%) compared with non-attenders (37% to 34%). (4 and 5) Rounds were described as interesting, engaging and supportive; four contextual layers explained the variation in Rounds implementation. We identified four stages of Rounds, ‘core’ and ‘adaptable’ components of Rounds fidelity, and nine context–mechanism–outcome configurations: (i) trust, emotional safety and containment and (ii) group interaction were prerequisites for creating (iii) a countercultural space in Rounds where staff could (iv) tell stories, (v) self-disclose their experiences to peers and (vi) role model vulnerability; (vii) provide important context for staff and patient behaviour; (viii) shining a spotlight on hidden staff and patient stories reduced isolation and enhanced support/teamwork; and (ix) staff learned through reflection resulting in ripple effects and outcomes. Reported outcomes included increased empathy and compassion for colleagues and patients, support for staff and reported changes in practice. The impact of Rounds is cumulative and we have identified the necessary conditions for Rounds to work.


Rounds outcomes relied on self-report, fewer regular attenders were recruited than desired, and it was not possible to observe staff post Rounds.


Rounds offer unique support for staff and positively influence staff well-being, empathy and compassion for patients and colleagues.

Future work:

The adaptation of Rounds to new contexts and to increase reach needs evaluation.


The National Institute for Health Research Health Services and Delivery Research programme.


About the Series

Health Services and Delivery Research
ISSN (Print): 2050-4349
ISSN (Electronic): 2050-4357

Article history

The research reported in this issue of the journal was funded by the HS&DR programme or one of its preceding programmes as project number 13/07/49. The contractual start date was in September 2014. The final report began editorial review in March 2017 and was accepted for publication in July 2017. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Declared competing interests of authors

Jill Maben reports that she was a member of an advisory group from 2006 to 2009, advising on the development of the Point of Care project at The King’s Fund, and a member of the Point of Care Foundation (PoCF) Board 2013–14; she stepped down as board member at the start of the evaluation. Jeremy Dawson reports that he is a board member of the National Institute for Health Research Health Services and Delivery Research programme. Shilpa Ross and Laura Bennett report that they are currently employed by The King’s Fund, and Catherine Foot reports that she was previously employed by The King’s Fund. The PoCF, which supports the implementation of Schwartz Center Rounds® in the UK, was set up in 2013 by colleagues who were previously also employed by The King’s Fund between 2007 and 2013.

Last reviewed: March 2017; Accepted: July 2017.

Copyright © Queen’s Printer and Controller of HMSO 2018. This work was produced by Maben et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Bookshelf ID: NBK533087PMID: 30431750DOI: 10.3310/hsdr06370


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