Summary of the approach
This was an interpretivist study. The author conducted interviews with members of her organization about their feelings of stress. The findings were used to develop a questionnaire, entitled ‘The Organizational Response to Emotions Scale’ (Additional file 1: Appendix 1). This was administered at two time points; the start and end of the Schwartz Rounds. The aim was to capture shifts in feelings or beliefs that might accompany a more collective perspective.
Theories that have informed the approach
The study was informed by theories of emotional labour [52, 60], and stress [54]. The author also drew upon the social psychology literature, including work on depersonalization [108] and dehumanization [18].
Aims and objectives
The overall aim of this study was to examine whether Schwartz Rounds promoted the well-being of staff and reduced the stress inherent in their work.
Objective one
To examine levels of staff stress in the author’s trust before and after the implementation of Schwartz Rounds.
Objective two
To examine the way in which staff describe their feelings of stress, before and after their attendance at the Schwartz Rounds. The findings will be considered in the context of the implications for patient care.
Objective three
To examine the way in which staff feel about their colleagues, before and after their attendance at the Schwartz Rounds. Reported levels of interconnectivity may serve as an index of withdrawal and ergo, hold significance for patient care.
Case study structure
The case study will begin with a literature review on the psychological defence mechanism of withdrawal, in the context of healthcare. The methodology section details the mixed methods approach that the author employed in the study. This helped to reveal new insights into the way in which stress shapes relationships between staff. During the final discussion and conclusion sections, the implications of the findings are discussed in respect of wider organizational and political contexts.
Literature review
The psychological defence of withdrawal was first brought to the public’s attention by The Francis Inquiry [39] into Mid Staffordshire NHS Foundation Trust. Scores of patients died unnecessarily as a consequence of neglect. A contributory factor was the behaviour of frontline staff. Nurses were found to be preoccupied with activity and performance data [27, 63]. Disturbingly, many had also become detached from their caring role and appeared desensitised to the needs of vulnerable people under their care [13, 107].
Sir Francis concluded that the behaviour of the staff was a manifestation of a toxic and dysfunctional culture [39]. At the heart of this lay systemic failures of leadership [88]. It emerged that managers had overlooked significant staff shortages [14]. At the same time, they had routinely employed pace setting and top-down techniques to ‘inculcate staff’ [10] into prioritising organizational targets [25]. In a large number of cases, their methods had spilled over into bullying and blame [2]. Francis [39] argued that sustainable culture change would only be realized if the NHS adopted compassionate and collegiate styles of leadership. A subsequent report on patient safety conducted by Professor Don Berwick [11] echoed these sentiments. Berwick concluded that leaders should ‘abandon blame as a tool and make sure pride and joy in work, not fear, infuse the NHS’ ([11], p.5).
The tabloid media initially overlooked the fact that staff had suffered too and lambasted the nurses for having ‘stopped caring’ ([23], p.1). Keen to allay the public’s fears, the government hastily announced plans to mandate compassion [113] and criminalise neglect [9]. However, this response was later roundly criticized for compounding the demonization of staff [109]. It was also naïve because it served to address the symptoms of the problem, rather than the deeper cause.
The need to improve the quality of care is indisputable. However, as will now be illustrated, focussing vigilantly upon the needs of people who use the NHS is only one part of the solution.
A narrow focus upon the recipients of care
In October 2014, NHS England, under Sir Simon Steven’s stewardship, published the much-lauded Five Year Forward View [85]. The document highlighted that the NHS remained too preoccupied with disease-based care and needed to realign itself to focus on prevention. It argued that the success of this would hinge upon staff adopting person-centred models of care.
The central message is not in question. However, it must be considered in the context of the fact that up to 75 % of change initiatives within the NHS are thought to fail to achieve their objectives [8]. A glaring omission, which threatens to consign the Five Year Forward View to the same fate, is that it did not address whether frontline staff have the skills [93], emotional resources and support to provide a higher degree of relational care.
Staff within health and social care sectors are known to experience significantly greater levels of work-related stress, when compared to other professional groups [58]. The picture appears to be getting worse: figures released under the freedom of information act in 2015, revealed that absence due to mental health difficulties has doubled in recent years [87]. This equates to a loss of 1.6 million working days [12] with an estimated cost of £2.4 billion per annum [92].
Exposing an organizational blind spot
In the same month that the Five Year Forward View [83] was published, the CQC announced that they would be transforming their regulation process (CQC, [17]). The organization had faced criticism in the wake of the Francis report that it was too ‘light touch’ ([15], p.1) to detect a problem similar to that found at Mid Staffordshire [1]. The new framework, which was based on the work of Professor Michael West at The Kings Fund, awarded a higher priority to staff wellbeing and included an assessment of staff engagement for the first time [112]. This shift in focus, coupled with increasing evidence that staff wellbeing is an antecedent, rather than a consequence of quality care [70], helped to raise awareness of the implications of staff stress at a policy level [83].
In 2015, NHS England and NHS Employers responded by launching a range of initiatives, including improved nutrition and fitness schemes [84] and a self-help ‘emotional wellbeing’ toolkit [82]. Although these are a step in the right direction, they do not go far enough. At the heart of the problem is that they place the ‘locus of the disturbance’ (Balme et al., [4], p1) upon the individual. In doing so, they fail to pay due regard to the role of wider social and organizational issues ([66], Sawbridge, 2015: Email communication); the key factors that were highlighted within the Francis report [39].
This individualistic approach to staff wellbeing within the NHS is unfortunately longstanding. In the 1980s and following the advent of the internal market, mental ill health amongst employees tended to be viewed as indicative of ‘neurotic tendencies’ (Rose, 1982 cited in Bamber, [5], p4). In recent years, attention has shifted to staff members’ response to providing direct patient care.
The provision of care: the source of the stress?
The notion that nursing staff dehumanize and distance themselves from those under their care was introduced by the psychoanalyst Menzies Lyth, in 1960 [77]. Following a four year ethnographic study within a teaching hospital, she argued that nurses employed unconscious defence mechanisms in order to cope with the ‘primitive anxieties’ ([77], p.452) aroused as a consequence of working with people who were ill or dying. Critically, she also asserted that the ‘defence system’ (p.453) within the hospital, not only failed to address the nurses’ anxiety but, by failing to provide them with sufficient reassurance and satisfaction, it also created secondary anxiety. Although the findings were acclaimed by scholars within her field, they did not translate into meaningful changes for staff. In 2009, Lawlor suggested that this was because Menzies Lyth did not, ‘address adequately what to do about it’ [the anxiety] ([64], p. 528).
A more contemporary theory of staff withdrawal, which has achieved broader appeal, is that provided by the theory of ‘emotional labour’ [52, 60]. This has been defined as, ‘Supressing private feelings, in order to show desirable work-related emotions’ ([76], p.4). A key tenet of the theory is that service workers are routinely subjected to regulation and control of their feelings, emotional expression and personality [52, 60]. The control is asserted by managers via the reinforcement of ‘display rules’ (Ekman and Friesen, 1969, cited in [98]). An example of this would be a nurse displaying patience and compassion, in the face of incivility from a family member.
Over time, the mismatch between expressed and felt emotions is thought to lead to ‘emotional dissonance’ [118] and ultimately, emotional strain. This, in turn, increases the risk of burnout, characterised by feelings of emotional exhaustion, reduced professional efficacy and cynicism (Maslach et al., [74]). In parallel with Menzies Lyth’s [77] ideas, staff are seen to withdraw from patients and depersonalize or objectify them, in order to cope [47].
Emotional labour and Schwartz rounds
An important premise of Schwartz Rounds is that the sessions promote compassionate care by supporting staff with the ‘emotional aspects of their work’ ([105], p.1). To date, this has however, proven difficult to evidence. Although two pilot studies suggest that Schwartz Rounds can yield improvements in compassionate care [69] and team working [46, 45] these studies are beset with methodological flaws and weaknesses and, as such, are not seen as ‘robust’ ([71], p.2). This may pose a risk to the future sustainability of this form of support. Another issue, as highlighted by Lloyd et al. ([68], p.182) is that if we do not understand how or why an intervention works, we are unable to ‘maximise its effectiveness’.
It is possible that a barrier to explicating what is happening within the Schwartz Rounds is the focus upon emotional labour. Observations suggest that the theory is not able to explain the depth of the changes that staff report anecdotally. Another issue, which might undermine its applicability for healthcare more generally, is that emotional labour does not capture the complexity of the relationship between the provision of care and the feelings of burnout that lead to withdrawal. The relationship is clearly not linear. Staff who have an insecure attachment style [40, 65] and previous experience of trauma [81] appear to be more vulnerable to burnout. Moreover, wider aspects of organisational culture has been found to play a much greater role in the development of burnout, when compared to patient care [110] or individual factors [49].
Lastly, the theory of emotional labour cannot account for ‘interactive’ factors. As highlighted by Tang [103], this encompasses;
‘…how the behaviour (and emotions) of the different parties to the interaction, e.g. the manager, colleagues and the recipient both interpret and affect the emotional labourer and their performance’ ([103], p.18).
As will now be discussed, emerging research suggests that the therapeutic processes that are at play during the Schwartz Rounds might be better explained by more basic psychological model of stress.
Stress: the precursor to withdrawal
The experience of stress has been defined as:
‘The psychological and physiological state of a person responding to demands that stressors in an environment place upon them (i.e. strain) under conditions where those stressors are perceived to be threatening to the self and well-being’ ([54], p.355).
This quote is helpful because it draws attention to the fact that an individual’s experience of stress is mediated by their appraisal of it. This can be understood more clearly if we recognise that the primary evolutionary function of stress is self-preservation [101]. What has not hitherto not been recognised, although makes intuitive sense, is that this brings with it a reduction in compassion for others.
Psychologists have known for some time that anxiety triggers changes in brain activation (Arnsten, [3]). This apparent evolutionary survival response is adaptive in some circumstances because it leads to a narrowing of focus, evidenced by improvements in selective attention [96]. In 2015, Todd and colleagues further elucidated this process, by demonstrating that feelings of stress also heighten ‘self-focussed attention’ ([106], p. 375) which, in turn, undermines perspective taking. Converging research subsequently revealed that this acquired egocentrism is associated with a reduction in empathy for others [73].
A possibly related issue, that does not appear to have been addressed by the literature to date, is the feeling of threat that might arise from the experience of stress itself. Evidence from mental health research suggests that this is likely to be shaped by cultural perspectives [50]. People who are from ‘collectivist cultures’, such as China ([94], p. 13) tend to use situational explanations for human behaviour [75]. In contrast, individualistic cultures, such as North America and Western Europe, are more likely to emphasise ‘personal causality’ ([94], p. 13). These differences are reinforced by the media [78].
This has relevance for the current study. It seems reasonable to suggest that a situational appraisal of stress would not represent a threat to personal identity and therefore, may be less likely to trigger withdrawal. The opposite scenario can be imagined for dispositional attributions of stress.
Putative new theory to explain the benefits of Schwartz rounds
Comments made by attendees at the Schwartz Rounds indicates that hearing others’ self-disclosures helps them to shift from dispositional, to more situational appraisals of stress. They come to recognise that stress is normal in the context of a highly pressured and often poorly resourced healthcare service. This disconfirmatory evidence helps them to challenge the beliefs that underpin and maintain their withdrawal, for instance, ‘Everyone else is coping; I am the only one who is struggling’. It may also alleviate a potent secondary source of anxiety; the fear of negative social evaluation [31, 32]. This self-perpetuating process is outlined in Fig. 1.
Reduced empathy for others is considered to lie ‘at the heart of dehumanization’ ([18], p.1). It is conceivable that the increase in interconnectivity and compassion that is reported by attendees of the Schwartz Rounds, would translate into important benefits for patient care. This is likely to operate indirectly. An improved sense of cohesion should lead to an associated increase in social support and a concomitant reduction in anxiety. Over time, this should result in fewer instances of withdrawal.
In the following sections of the case study, the author will outline the approach that she took to exploring these concepts.