Acknowledgements
I would like to thank the Florence Nightingale Foundation for the opportunity to undertake this piece of work and for all those who interviewed me and not only recognised my commitment and potential but challenged me to consider more deeply how I could explore practice and share my learning.
I would like to offer my heartfelt gratitude to the James Tudor Foundation for supporting my travel scholarship – without such generosity I would never have had the opportunity to learn from colleagues in the US.
Also I would like to acknowledge the support that I have had from my colleagues in the organisation in which I work and our partner Universities– to my colleagues who had the confidence in me to provide references that supported my application for the travel scholarship; our Chief Executive who first introduced me to Schwartz Rounds; to my fellow Facilitators and Clinical Leads who are inspirational and our team working allows our work to continue and to all my colleagues and friends who have supported me in and out of my daily work.
Abstract
My travels enabled me to consider in more depth the facilitator role within the Schwartz Centre Rounds – I had the time to observe in detail, time to think, time to consider and time to reflect up on my own practice as a facilitator whilst learning from other facilitators both in the US and closer to home in Wales.
A Schwartz Centre Round is typically a monthly forum at which health care practitioners from all staff groups consider the caring and human dimensions of their work. The approach whilst originally modelled on the idea of a medical grand round includes a presentation of a case or scenario and then encourages an opportunity for discussion with an audience of colleagues.
During my observations of Schwartz Centre Rounds I focused up on what it was that the facilitator did and what difference did the facilitator role have on the panel, on the audience and on the outcomes of the discussions.
My report puts in to context the purpose of the Rounds, facilitation skills in a general sense and the role of facilitation specifically in the Rounds. I consider the things I learnt in the US where Rounds have been running for twenty years and how this learning can influence the Rounds in my own place of work were we have been running them for two years and those other organisations in Wales where the Rounds are at an embryonic or infancy stage.
Perhaps it would be a good idea,
fantastic as it sounds,
to muffle every telephone, halt every motor,
and stop all activity some day
to give people a chance
to ponder a few minutes on what it is all about,
why they are living and what they really want.
- James Truslow Adams
1878-1949
Index
1. Acknowledgements 2
2. Abstract 2
3. My travels 5
3.1 Schwartz Centre Rounds 5
3.2 Facilitation 7
3.3 Facilitator role 9
3.4 Travelling to Boston & Schwartz Centre for Compassionate Care 10
3.5 My observations 11
3.6 A variation on a theme 14
3.7 Things that people say at a Round 15
4. Conclusion 16
4.1 Impact on the Health Board
4.2 Impact on me
4.3 Impact on a wider audience
5. Recommendations 18
5.1 Sharing with mentors
5.2 Facilitators network
5.3 Publishing work
5.4 Travel
6. Bibliography 19
My travels
I am a Registered General Nurse with over thirty years experience the first twenty of which in a clinical background of a variety of critical care settings culminating in seven years as a Senior Sister in a cardiac intensive care unit. During this time I led the unit to be accredited as the first Practice Development Unit in Wales and worked with Leeds University as an accreditation panel member to support other units through the same process in Ireland and the US.
I have worked since 2005 in Practice Development Nurse roles, facilitating the Royal College of Nursing (RCN) Clinical Leadership Programme in the Health Board as well as other in-house leadership and management programmes, devised and led a training programme for clinical supervisors; trained as an RCN Union Learning Representative and support members within the Health Board and colleagues across South Wales.
In my current role, as Head of Nursing Education and Research, I am responsible for mentorship for pre-registration nurses as well as post graduate contracts with two partner Universities; I lead on projects such as the current drive with NMC revalidation; I lead on HCSW roles and development; I support registrants and non-registrants with meeting their personal and professional development plans falling out of their PDR’s and I liaise with colleagues in our research and development team to ensure nursing is included and leading were appropriate.
I trained with the Point of Care Foundation as a Schwartz Centre Round Facilitator and introduced the Rounds in to our Health Board.
3.1 Schwartz Centre Rounds
Schwartz Centre Rounds (Rounds) were developed by the Schwartz Centre for Compassionate Care in 1995 following the death of Kenneth Schwartz who, during his treatment for lung cancer, noticed how some health care staff struggled to deliver care in a compassionate way all of the time (Schwartz, 1995). The Rounds are running in over three hundred organisations in the USA and one hundred and four in the UK.
The Schwartz Centre was established as a non profit organisation designed to nurture compassion in health care staff - the premise being that caregivers are better able to make personal connections with their patients and colleagues when they have insight in to their own responses and feelings and also when they have the opportunity and space to process these feelings through shared experiences with colleagues (Schwartz, 1995). The Schwartz Centre undertook an evaluation in 2008 to consider the impact of the Rounds on self reported changes by those who attended, about their beliefs about patient care, their behaviour, their role in teams and their sense of stress. Lown and Manning (2010) reported the findings of this study to include an enhanced likelihood to attend to psychosocial and emotional aspects of care, reported improved teamwork and a decrease in stress.
Whilst there are now one hundred and four organisations running Rounds in the UK the initial pilot of two hospitals was evaluated by Goodrich (2011). The purpose of the evaluation was to test whether Rounds could transfer successfully from the USA to the UK. This evaluation used feedback from participants in a pre and post Round questionnaire and interviews with key staff from both hospitals. Goodrich’s findings (2011) reported a strengthening of teamwork, noteworthy changes in hospital culture, staff feeling less isolated and more of a part of the whole organisation and an increased sense of pride in their work. The limitations of this evaluation, compared to the USA work, include the small numbers involved in the questionnaires and no observations of the Rounds or practice. Goodrich (2011) however concludes that the evaluation did demonstrate successful transfer from the USA to the UK sites and that similarities in the two pilot UK sites were more marked than any differences. The Point of Care Foundation were encouraged by this evaluation and continued to facilitate the spread of Rounds across the UK. The Point of Care Foundation provides advice and support with particular emphasis on the training of Round Facilitators that will be discussed in more detail. Once the Rounds are established in an organisation it is anticipated that they will run indefinitely (Point of Care Foundation, 2014).
The Francis Inquiry (2013) highlighted major shortfalls in the provision of care to patients and a widely acknowledged the need to find ways to better support staff in the delivery of compassionate patient care. Francis (2013) recommended the Rounds as an intervention that organisations could use to enhance the quality of patient care by providing emotional support to staff members. The regularly facilitated meetings where staff can explore the emotional and social challenges of providing compassionate care in a safe and non-challenging environment where supported by both Francis (2013) and the Department of Health (2013). At the time of the Francis inquiry there were twenty-three organisations in the UK running rounds and by 2015 this increased to one hundred and four (Point of Care Foundation, 2015). Whilst this demonstrates a real energy/ investment for supporting staff the question of sustainability is also very real in the current financial picture for the NHS and UK economy as a whole.
Undoubtedly the need to support staff through the Rounds is evident and further supported by Bodenheimer and Sinsky (2014) when they discuss the negative impact that staff burnout and dissatisfaction has on patient satisfaction and outcomes. Myers (2014) concurs with this work when she describes the positive impact on team working and patient care that providing staff with the space to reflect and discuss the challenges in delivering compassionate care can have on them. There are of course challenges within this when staff from different professional groups question the validity of data gained through stories (Myers, 2014). A determination to dismiss a story as not being rigorous evidence or perhaps a ‘one off’ incident is an example of when one form of ‘knowing’ is more valued than another – Francis (2013) tells us that this situation can cause exclusion, loss of information and warning bells about culture not being heard. It is important that all forms of data are acknowledged because whilst different they will all have their value (Wittgenstein, 1998) – something that can be applied to people as well as data.
With a rapid increase in the uptake of Rounds in the UK it could be that further research is needed to explore in more depth the impact on staff and ultimately on patients experiences of compassionate care.
3.2 Facilitation
With the focus on asking and listening, instead of telling, facilitation can build consensus and support collaborative working – it is an essential skill for anyone working with others (Bens, 2012). Beckhard (1969) describes how the facilitator role would not have been recognised prior to the mid twentieth century, when theorists working in the field of behavioural science described the need for a leadership style that could contribute positively to the complex structures in groups, without answering questions and directing outcomes. A facilitator supports a group or team to work together – the facilitators’ role is to manage the process whilst leaving the content to the participant (Havergal and Edmonstone 2003). Facilitators operate from a set of principles the core of which is a belief in people; this includes that people are capable; they want to do the right thing with real commitment to plans that they have been involved in the creation of (Bens, 2012; Harvegal and Edmonstone 2003). Facilitators work to the principles that people can be trusted to assume responsibility for their decisions and actions, that groups can manage conflict and behaviours if the process of facilitation is designed and applied honestly (Bens 2012). Surowiecki’s work (2004) tells us that when facilitation supports group thinking and decision making the group can make better decisions than any one individual could make alone. Within the health care setting many facilitators develop from an already established education role – this shift in role can be difficult, no matter the background, as a move from a didactic teaching role to an interactive facilitation role requires considerable effort as well as acquiring, or developing, a new skill set (Westberg and Hilliard, 1996). In contrast to a teaching role when the one person could potentially provide the agenda, the content, deliver the information, direct the learning and conclude the session, the facilitation role is one that brings structure to the work through process. The content is driven by the group and the facilitator will help the group create rules of conduct, will probe to encourage a deeper exploration of discussion points, offer tools and techniques to support this exploration whilst ensuring participation by all group members (Westberg and Hilliard, 1996; Reddy, 1994 and Kinlaw, 1993) and Bens (2012) discusses that there are other skills key to facilitation such as helping constructive management of differences, redirecting ineffective behaviours and providing feedback.
Within health care settings education has traditionally been delivered in professional groups, however this has changed beyond all recognition in recent years (Egan-Lee, Baker, Tobin, Hollenberg, Dematteo and Reeves 2011) and staff from professional groups are increasingly learning together both informally in practice and in formal academic settings. This interprofessional education has led to development of facilitation skills that may be considered differently when two or more health professionals learn with and from one another (Sargeant, Hill and Breau, 2010). In addition to the facilitation skills already considered when working with interprofessional groups, the facilitator is required to be committed to this type of learning environment and whilst credible in one’s own professional community also has an understanding of sources of tension/ difference between professions (Egan-Lee, Baker, Tobin, Hollenberg, Dematteo and Reeves, 2011). Lundqvist and Reeves (2007) describe how the facilitator will need to be flexible as well as confident in their approach to the management of professional differences as well as understanding the preparation implications for facilitators working with interprofessional groups. The literature points to interprofessional learning being seen by some as one profession teaching a group of learners from a different profession as opposed to working in a mixed professional group (Egan-Lee, Baker, Tobin, Hollenberg, Dematteo and Reeves, 2011). Merriam, Caffarella and Baumgartner (2006) support the mixed professional group and contend that they are not only learning with but also learning from and about each other.
Sargeant, Hill and Breau (2010) define interprofessional learning as being an interactive process that leads to an improvement in collaborative working and in the quality of care. They describe a focus on interaction and shared learning with the skills of the facilitator being of paramount importance. The constructivist nature of interprofessional learning does call for learners making sense of their learning and the meaning of it (Merriam, Caffarella and Baumgartner, 2006) and this requirement further calls for the notion of the facilitator moving away from any didactic teaching approaches (Westberg and Hilliard, 1996) and apply interactive facilitation skills. Anderson, Cox and Thorpe (2009) call for preparation of those aiming to achieve effective interprofessional learning and this would include consideration of appropriate pedagogical practices so that facilitators can light the way and enable learning. Established and experienced facilitators may well experience some difficulties in changing approaches to support interprofessional learning and they will need support from others at times if they are to foster collegial working (Lindqvist and Reeves, 2007).