The Schwartz Centre Rounds: Supporting mental health workers with the emotional impact of their work

In healthcare settings, there is an emotional cost to caring which can result in compassion fatigue, burnout, secondary trauma, and compromised patient care. Innovative workplace interventions such as the Schwartz Rounds offer a group reflective practice forum for clinical and non-clinical professionals to reflect on the emotional aspects of working in health care. Whilst the Rounds are established in medical health practice, this study presents an evaluation of the Rounds offered to mental health services. The Rounds were piloted amongst 150 mental health professionals for 6 months and evaluated using a mixed-methods approach with standardized evaluation forms completed after each Round and a focus group (n = 9) at one-month follow-up. This paper also offers a unique six-year follow-up of the evaluation of the Rounds. Rounds were rated as helpful, insightful, and relevant, and at six years follow-up, Rounds were still rated as valuable and viewed as embedded. Focus groups indicated that Rounds were valued because of the opportunity to express emotions (in particular negative emotions towards patients that conflict with the professional care-role), share experiences, and feel validated and supported by colleagues. The findings indicate that Schwartz Rounds offer a positive application in mental healthcare settings. The study supports the use of interventions which provide an ongoing forum in which to discuss emotions, develop emotional literacy, provide peer support and set an intention for becoming a more compassionate organization in which to work.


INTRODUCTION
Compassion in healthcare settings has been ranked by patients and their families as being amongst their greatest healthcare needs (Heyland et al., 2010). However, a review by Sinclair et al. (2016) found professionals' capacity to provide compassionate care could be limited by educational deficiencies, practice-setting hindrances (e.g. lack of time, staffing, and resources) and negative workplace cultures.
Improving healthcare professionals emotional support at work is an important objective to contribute to their well-being, resilience, and, ultimately, patient satisfaction. Recently, UK hospitals initiated the Interim People Plan (2019) amongst which two of its principle aims were to i) set a vision for how health professionals will be supported to deliver care; and ii) promote positive working cultures and build a support network of compassionate leaders'. Frameworks to encourage investment in staff well-being to facilitate compassionate care are available, such as 'Thriving at Work' (Stevenson & Farmer, 2017). Thriving at Work outlines what employers can do to better support employees, including those with mental health problems, to remain in and thrive through work. A second framework, called Developing People-Improving Care (Care Quality Commission, 2016), aims to guide team leaders to develop a set of improvement and leadership capabilities amongst teams.
Compassion was outlined as a core value in the constitution for UK hospitals, so that professionals can give good quality care to provide comfort and help relieve suffering. However, Chadwick argued that compassion is an untrainable quality, occurring in a spontaneous manner (Chadwick 2015) and suggested that Schwartz Rounds might offer staff an opportunity to express their feelings and remain empathic towards their patients.
The Schwartz Rounds were inspired by healthcare service user Kenneth Schwartz. Kenneth Schwartz recognized that it was the authenticity, individual (rather than just professional) contact, and compassion shown to him by professionals, which made all the difference to his care. He recognized that compassionate care could only develop from professionals in a compassionate setting, and this required attention to the emotional distress of healthcare employees. After Kenneth Schwartz died, the Schwartz Centre for Compassionate Care was set up and they established the Schwartz Rounds in the USA. In 2009, the Kings Fund piloted the Schwartz Rounds at two sites in the UK (Goodrich, 2012). The initial findings suggested positive outcomes, and the Schwartz Rounds are now being delivered in over 116 UK hospitals and hospices (Robert et al., 2017).
Further UK-based studies found that Rounds improved professionals' relationships; sense of cohesion and common purpose (Reed et al., 2015); communication and normalizing of emotions (Barker et al., 2016); insight (Chadwick et al., 2016); reduced perception of emotional labour; improved insights that helped them care for their patients and improved their understanding of how colleagues felt (Hughs, Duff & Puntis, 2018); facilitated active reflection and identification of learning needs (Stocker, Cooney, Thomas et al., 2018); and were perceived as less stigmatizing than traditional forms of occupational health (George, 2016). Pepper et al. (2012) suggest that Schwartz Rounds allow attendees to reflect on their practice whilst exploring the emotions that arise from working with clients and that is in turn can revive compassion, improve staff well-being (Goodrich, 2013), and combat compassion fatigue (Thompson, 2013). A recent review of the Schwartz Rounds literature and an independent assessment across 10 sites delivering Schwartz Rounds (Taylor, Xyrichis, Leamy, et al., 2018) found that attendees of Schwartz Rounds showed a 50% reduction in psychological distress, providing consistent evidence for the benefits of Schwartz Rounds. The review (Taylor et al., 2018) also found increased empathy and compassion for colleagues and patients.
The Schwartz Rounds were also implemented in the USA and Canada where they were effective in improving: service users' overall health, staff work satisfaction, and staff sickness records (Lown & Manning, 2010); communication with co-workers including more personal conversations with supervisors; and perspectivetaking .
A review by Johnson et al. (2017) found that staff in mental healthcare settings reported poorer well-being than staff in other healthcare settings. This is associated with reduced quality and safety of patient care, higher staff sickness and turnover rates (Johnson et al., 2017), and barriers to compassion (Dev et al., 2018). Mental health professionals face highly emotional situations, such as supporting people who are suicidal, hearing about traumatic events, and being subject to patient violence and threats (R€ ossler, 2012). Evans et al. (2006) found that low control over caseload, high job demands, and feeling unsupported were key compo-nents in excessively high levels of stress in mental health workers. The UK Government has set targets and dedicated funding for increasing staff in priority areas such as mental health. However, with rates of staff attrition (Limb, 2017) and sickness due to stress in healthcare workers increasing, it is clear that the burden on professionals' well-being and the burden on the quality of patient care need to be addressed with ongoing interventions which support emotional literacy, emotional sharing, and compassion. There is a wealth of evidence for the effectiveness of Schwartz Rounds in medical healthcare settings (for review see Taylor et al., 2018); the current study will assess whether Schwartz Rounds might be a means to support healthcare professionals working in mental healthcare settings.

Aims
This research aims to evaluate a rare incidence of the Schwartz Rounds being applied within a mental health setting as opposed to a physical health or palliative care setting (Robert et al., 2017). The research aimed to evaluate mental health professionals experience of the Rounds using a mixed-methods approach comprising data collection through standardized evaluation forms, Focus Groups, and Facilitator notes taken during the Rounds. The research also aimed to conduct a longterm follow-up period of six years since the initiation of the Rounds in this mental health setting (the longest previous known follow-up period was one year Reed et al., 2015).

METHOD Design
The evaluation study utilized a mixed-methods approach comprising the following: i) quantitative measures in the form of a standardized evaluation, ii) qualitative measures in the form of a Focus group, and iii) qualitative examination of the Round Facilitators notes taken during Rounds.

Evaluation form
A standardized 9-item evaluation form designed by the Kings Fund (Cornwell & Goodrich, 2010) was completed by mental health professionals following each monthly Schwartz Round over a six-month period. Eight questions evaluated the relevance of the Rounds to the participants' work, general usefulness, and how likely participants would be to attend other Rounds. Participants scored each question on a five-point Likert scale of 0 to 4, 0 being 'Disagree Completely' and 4 being 'Agree Completely'. Question nine asked the participant's professional affiliation. Participants had the option of writing any comments. Further demographic data were not collected as this does not form part of the Kings Fund standardized evaluation form. All evaluation data were analysed using SPSS version 22.

Focus group
A focus group interview was used to yield rich experiential data and to bring the researcher in direct contact with key individuals (Clarke, 1999). The focus group sample (N = 9) was a purposive sample of mental health professionals working at a UK mental health hospital who had attended more than one Schwartz Round. Participants were approached to take part in a focus group by a researcher (author KM) via email. Professionals who had attended more than one Round were invited to the focus group, and nine responded to the email and attended (7 females, 2 males) alongside an independent qualitative researcher. The focus group took place at the participants workplace for their convenience.
An independent researcher was selected to conduct the Focus Group to minimize demand characteristics and bias. A focus group was conducted at one-month follow-up to the pilot by an independent female Research Assistant (author SC) who had no prior relationship with the participants. At the start of the focus group, the interviewer informed the participants that she was an independent Researcher with experience in qualitative research having just completed a PhD using solely qualitative methods. The researcher shared her personal goals which were to gain post-doctoral research experience. The researcher also shared the aims of the focus group which were to capture the experience of attendees, to explore whether or not the Rounds were useful, and to discern possible improvements.
The following ten questions formed the focus group schedule and were approved by a representative of the Kings Fund as being relevant to attendees and being likely to elicit useful information beyond their standardized evaluation forms: i) What is your overall impression of the Schwartz Rounds? ii) What did you like about it? iii) What did you dislike about it? iv) What did you think format of the Rounds and cases presented? v) How helpful did you find the Schwartz Rounds? vi) In what way has it helped you? vii) Can you tell me about your experiences of working in an inpatient unit after the introduction of Schwartz Round? viii) Has there been any impact of the Schwartz Rounds on your personal or work life? ix) Are there any possible barriers or benefits of attending the Rounds regularly? x) Is there anything you feel we haven't talked about today that you would like to add?
The 40 min focus group was audio-recorded and transcribed, and the transcripts were analysed by the primary researcher (DA) using thematic analysis (Braun & Clarke, 2006) in NVIVO. Themes were independently extracted and double-coded by a second researcher (KM). Following Braun & Clarke's six phases of analysis, the two researchers i) familiarized themselves with the data; ii) generated initial codes; iii) searched for themes; iv) reviewed themes; v) defined and named themes; and vi) produced a draft report for discussion and agreement. An inductive approach was used with the themes deriving from the data, without pre-conceptions.

Facilitators notes
It is usual practice in Schwartz Rounds for the facilitator to take notes summarizing the meeting. To capture salient themes occurring during the Rounds, additional content analysis was conducted by an independent researcher (RE) on the Round facilitator's discussion notes. Themes were extracted and double-coded by a second researcher (KM).

Ethics
Ethical approval was obtained from the Research and Development team at Derbyshire Healthcare NHS Foundation Trust and was excluded from REC review as it was with professionals (GAfREC). All participants gave informed consent to participate in the evaluation and to their anonymized data being used in publication. All quotes presented from the focus group are given under the pseudonyms created by the participants. No participants withdrew from the study or refused consent; however, the Schwartz Rounds are an optional meeting and attendance is at the discretion of professionals.

Participants
The pilot was undertaken within an inpatient acute psychiatric unit at Derbyshire Healthcare NHS Foundation Trust. The unit consisted of four inpatient wards, offering 92 beds for acute psychiatric care, including enhanced care. Services within the unit were delivered by nursing care; healthcare assistance; psychiatry; occupational therapy; psychological assistance; catering; domestic support; administration; and building estates. The Rounds were open to all these groups. Also invited were the crisis resolution and home treatment team and the perinatal mental health team.
Professionals were invited to take part in the Rounds by the Chair of the Schwartz Round and a ward manager. A range of approaches was used to purposively target all 150 staff employed within the ward, through team meetings, informal discussions about the Rounds, emailing staffing lists, and posters. Lunch was provided as the Rounds were taking place in lunch hour.
The researcher (KM) invited 33 professionals who had attended more than one Round to participate in the Focus Group. Of these, nine professionals attended the focus group (27% of those eligible to attend).

Schwartz rounds
Schwartz Rounds are a monthly one-hour meeting that support a multidisciplinary team to discuss, listen, process, and understand any emotional distress arising from providing compassionate care and reflect on personal experiences of distress and ways of coping. The Kings Fund suggests that the Rounds can be used to address a variety of challenging topics, for example, working with patients whose pain is difficult to control; patients who are very destructive; or a terminally ill patient who reminds the professional of a family member.

Evaluation forms
A frequency analysis of the evaluation data is shown in Figure 1. Average responses per item ranged from 2.90 to 3.73 out of a maximum score of 4, indicating that the Rounds were rated as helpful, insightful, relevant, and with high intention to attend future Rounds.
Across the pilot period, the average evaluation form response was 3.42 out of 4, which suggested the Rounds were consistently positively rated. Across the Rounds, 43.3% of participants rated the Rounds as 'Excellent', with a further 30% rating them as 'Exceptional'.

Six-year follow-up
This paper also offers a unique six-year follow-up of the evaluation of the Rounds. Over a period of 18 months, evaluation forms from 231 Round attendees revealed that the Rounds were still consistently positively rated with an average response of 3.67 out of 4. Nurses were still the most represented profession attending the wards (62%), followed by doctors (25%), psychologists (17%), pharmacists (11%), and administrators (11%). Written comments on the evaluation forms suggest that Rounds are insightful, honest, cathartic, bring humanity to the profession, and are becoming more embedded in practice.

Focus group
Participants' comments from the evaluation forms were themed and included alongside the themes extracted from the focus group data analysis. Focus group quotes are illustrated by the use of a pseudonym for the speaker, whereas evaluation form quotes are depicted by the month of Round attendance and a letter depicting the different respondent's identity. Thematic analysis was used following Braun and Clarke's (2006) six phases of analysis. This initially produced seven themes (see Figure 2). The transcriptions were double-coded by a second researcher (KM) who generated five themes, and discussion took place between the two researchers to reach agreement. A sixth theme of 'validation of emotions' was merged with the theme of 'sharing similar emotions and experiences'. The seventh theme of 'feeling valued', which related to the time and financial investment by the hospital in provisioning the Rounds and catering, was dropped as there was only one participant who provided two quotes supporting this. There was high agreement on the resulting five themes.

THEME 1: THE EXPRESSION OF EMOTION
The largest emerging theme with the most comments concerned the expression of emotion during the Rounds. It was felt that the expression of negative, difficult, and conflicting emotions had been one of the THE SCHWARTZ CENTRE ROUNDS factors that had helped to make the Rounds feel useful and supportive. For many participants, it was a relief to be able to express negative emotions around patients and care situations, in an accepting, validating and non-judgemental environment.
November 2011 b. 'I liked the fact that the session felt genuinely supportive and insightful. Good to hear the acceptance of others thoughts, feelings and emotions evoked by distressing experiences'.
Participants commented on how the Rounds had helped them feel able to express both negative and positive feelings they held towards the service users under their care. This expression of emotion was felt to be beneficial to themselves and their relationship with their patients.
December 2011 b. 'Recognition that we can be angry and frustrated with patients/at their situation and express it authentically, honestly and constructively to benefit them'. 'Pat' 'I think it'd give you chance to vent in a safe environment. . .you've got a chance to vent your positive and your negative feelings in quite a protective place'.
Two participants noted that they found the Rounds discussions more useful when emotions and experiences were shared and noted that one of the discussions was not so helpful because it involved a monologue of things a person had achieved in the past and missed the point of the Rounds being a discussion of emotion and a show of vulnerability. 'Liz' 'When you found it useful it's about actually speaking about the experience and what you've been through, as opposed to this is what I've done'.

THEME 2: SHARING SIMILAR EMOTIONS AND EXPERIENCES
The second most prominent theme was that of how enlightening, helpful, and validating it was to listen to perspectives from colleagues across the Trust and to realize that they held similar emotions and experiences in common. In particular, participants felt relief and deshaming when sharing negative emotions and distressing experiences and realizing they had felt and experienced similar emotions, thoughts, and motivations. Furthermore, the sharing of feelings and perspectives had helped people to imagine themselves in similar situations, thus enhancing empathy for colleagues and acceptance over their decision-making and coping strategies.
'Ann' 'his reflections helped us to think about if we had been in that situation how we'd sort of coped with it and things'. of comments in this theme indicated that the Rounds had not been established long enough, that not enough people knew about them, or that attendance by the same individuals had not been consistent enough to have an impact on clinical practice, but that they might do over time. Two participants suggested that more regular Rounds or greater continuity of those attending would be helpful.
'John' 'It's a ventilation but it's unstructured, it's not frequent enough to go anywhere or to do anything other than to be an experience of itself. . . there's never the same set of people there, there's never a chance to develop cohesion, a sense of group, a sense of support'.
'Ann' 'This is a starting point and it's helping us to start to think about some of these issues and I think it's good that it's brought it to the forefront but it hasn't massively changed what I'm doing or how I'm approaching things on a day to day basis'.
One participant felt that the Rounds needed to be linked with lessons learnt and supervision in order to have a greater impact on practice.
It is important to remember that Schwartz Rounds are not intended as a form of supervision or a place to compose lessons learnt. Instead, a Round is the place to explore the emotional impact of the work upon people. However, as indicated by one of the focus group participants, the Rounds may be useful in conjunction with clinical supervision and/or meetings to improve practice.

THEME 4: TIME TO ATTEND AND TIME TO PROCESS THE ROUNDS
A few of the focus group participants highlighted how they had struggled to get the time to attend the Rounds regularly because of their shift system making it difficult to take a full lunch break. Many felt too busy and felt the demand of getting back to the ward. Some attendees struggled because the unit was not their main base. 'Jane' 'It's very difficult when you're on a shift pattern to get everybody because it's not ideal. We all have to go back for two o'clock, so you don't see the end of them. . . I've only managed to be here for half an hour of it, you know, or fifteen minutes and then I've had to go back to my ward so I've got the gist of it'.
A few of the participants commented on how their attendance at the Rounds had left them feeling emotional and how they had struggled to process the content of the Rounds, due to the need to return to work after the Round. 'Pat' 'because of timing, I was in charge of the afternoon shift so I had to go fifteen minutes before the end so we didn't see the end of it and a student nurse came with me and when we both left and said, 'whoah, that was quite powerful and emotional' but you had to go back to the ward and that was it, get back into the hustle and bustle of it all'.
Two participants felt that the Rounds did not provide enough time to allow closure for the strong emotions often raised by discussion and felt that more time was needed for discussion and that this might be easier in a smaller group and in members of the same team.
'John' 'I think Schwartz somehow just allows ventilation so there's no closure'.
'Mel' 'We can all have an input and go away and it feels like there's closure to it, rather than us all just coming in, listening and then it's all emotions that we all feel as well and then we just go off again'.

THEME 5: FINDING CONFIDENCE TO SPEAK
The findings suggest that it is people's ability to talk about their feelings that is a useful aspect of having the Rounds, but it is also important to ensure that people feel able to discuss their feelings, without fear of negative repercussions.
'Ann' 'I think it can be quite intimidating to speak up in a room where there's lots of people from lots of different teams. If this sort of thing was happening within the team that you worked in, you might feel more comfortable to put your point of view across but you might think "I don't know if this is going to come across right or there's lots of people looking at me, is it ok for me to say this?"'.
A few participants suggested that future Rounds could occur at a team level, to overcome some of these fears.
November 2011 b. 'Felt I would find it too daunting to present myself and that my experiences might seem trivial in comparison to today's session. Smaller group of people with whom you could build up trust over a period of time might make it easier for me to contribute with my own experiences'.
In sum, the application of the Schwartz Rounds in a mental health setting was largely seen as helpful and positive in terms of sharing distressing experiences and expressing negative emotions which conflict with a caring role. Some adaptations may be needed to ensure attendance and time to process the emotive content of the Rounds before returning to work. Furthermore, the Rounds could be more useful if they were linked to other meetings where problem solving could occur. Support was also needed to ensure that people felt safe to talk in Schwartz Rounds and be free from criticism or blame.

Facilitator's notes
A separate content analysis was conducted on the Schwartz Round facilitators (RE) hand-written notes. These brief notes are taken at every Round as a record of each presentation and its ensuing discussion.

CONFLICT BETWEEN HUMANITY AND PROFESSIONALISM
There was a pressure for staff to hide emotions from their patients and colleagues because there was a fear that these would be deemed unprofessional or a sign of weakness. This issue seemed particularly salient when an event sparked feelings of needing to withdraw (from a patient or a situation) and this was not allowed due to one's duty to provide care and maintain professionalism. For example '. . .showing emotions equals showing weakness and when one is in a leading position, other people would be scared to see me emotionally moved. . .', '. . .are we permitted the same human frailties as the service users we see?...', '. . .struggle with his feelings as he felt unprofessional. . .', '. . .needed to present a veneer of calm'.

FEELINGS OF GUILT OVER NEGATIVE EMOTIONS TOWARDS PATIENTS
There was frequent discussion about struggling with feelings of anger at work, particularly anger towards patients which often resulted in staff feeling guilty, '. . .would feel angry towards Mary and then feel guilty for feeling angry. . .', 'there is a feeling of guilt over feeling angry'. It was acknowledged that not expressing these emotions could have negative consequences for the quality of relationship with the patient. There was also a feeling that anger could be taken home and also cascaded through the organization if not addressed. Some staff acknowledged a need for more training in this area, '. . .expressing frustration and anger could cause problems, but if it was not expressed then the client may feel detached from you. . .'.

THE EMOTIONAL COST OF CARING
There were many instances of staff talking about the costs of caring including self-criticism; self-blame; guilt; taking anger and worry home; loneliness and isolation; and stress (which could also be seen as a sign of failure by colleagues), '. . .there was a recognition that there is a cost to caring. . .', 'people would instead take anger home', '. . .remained concerned and angry over the events therefore on leaving work found himself out looking for his patient. . .', '. . .went home that night and questioned whether she was in the right job. . .'.

DISCUSSION
To date, the Schwartz Rounds have been conducted and evaluated primarily in medical healthcare settings, whilst this study offers a rare evaluation of the Rounds in a mental healthcare setting. In addition to the routinely used standardized Kings Fund evaluation form, this study also offers a qualitative assessment how mental health professionals experienced the Schwartz Rounds, how helpful they were, details of barriers to attending, and whether the Rounds had an impact on professionals work life or personal life. The study also provided a six-year follow-up evaluation.
The evaluation forms completed in the pilot phase of the Rounds revealed that attendance at Rounds was high, with more than half of employees attending at least one Round. In general, attendees rated the Rounds as helpful, insightful, and relevant to their clinical roles with the majority of participants rating the Rounds as 'excellent' or 'exceptional'.
The six-year follow-up revealed that the Rounds were still rated positively, with comments such as finding the Rounds insightful, honest, cathartic, and bringing humanity to the profession. There were also more comments related to feeling that Rounds were becoming more embedded in practice (although similar to Taylor et al 2018, concrete examples were not given). It was suggested that further support for ongoing Schwartz Rounds could be through appropriate clinical supervision, team discussions, multi-disciplinary meetings to develop service user care packages, and team ethos about the role of emotions in work. Following the pilot, Derbyshire Healthcare NHS Foundation Trust decided to continue funding the Rounds and to make Round attendance more feasible to a wider audience by offering Rounds in three other organizations: University Hospitals of Derby and Burton, Derbyshire Community Hospitals NHS Trust, and East Midlands Ambulance Service. The Rounds are still currently offered by the hospital, and routine data collection is ongoing.
The main themes derived from the focus group highlighted two benefits to attending the Rounds, and these were i) the ability to express positive and negative emotions and ii) sharing similar emotions and experiences to colleagues and feeling empathy and recognition with colleagues' experiences. Consistent with the first theme, Taylor et al. (2018) found from their qualitative analysis across 10 sites running Schwartz Rounds that trust, emotional safety and containment, self-disclosure of experiences to peers and role-modelling vulnerability were important mechanisms which contributed to a positive experience of the Rounds. Chadwick et al (2016) also identified a theme of emotional insight, where professionals gained insight into the perspectives of the speakers and also gained new understanding of themselves and their own emotional reactions. Likewise in a thematic analysis of the Rounds,  found themes of normalizing and validating emotional experiences and sharing vulnerabilities. In support of the second theme (sharing emotions and experiencing empathy),  also found that professionals experienced greater empathy for their colleagues, a greater understanding of their colleagues roles, an increased willingness to approach colleagues for support, and a realization of common goals and connections to other teams.
The focus group also revealed some areas for improvement in the Rounds, and three themes emerged including i) a difficulty identifying changes to clinical practice; ii) finding time to attend the Rounds and finding time to process emotional content before returning to shift; and iii) finding it difficult to find the confidence to speak in front of others and talk about feelings in a large group (some professionals spoke of fears of negative interpretations about their emotional reactions). These fears were echoed in the facilitator's notes which found a conflict between expressing human emotions and appearing professional, and also feelings of guilt concerning feeling angry with patients. In addition, the facilitators notes revealed frequent discussions about the emotional cost of caring. Therefore, the Schwartz Rounds may be useful in the way they allow the sharing of emotive information and the discussion of emotive situations in a non-critical and nonblaming environment.
In the current study, attendees were not able to see how the Rounds might impact upon clinical practice at present, but this may occur at subtle levels and may emerge as the Rounds become more embedded. There is support for the theme of 'difficulty identifying changes to clinical practice' from Taylor et al (2018) who found that although professionals reported some subtle changes to practice in terms of new support groups for staff; changes in protocol; and different organizational conversations, they struggled to find concrete examples.  also found that changes to practice were subtle, and one example was improved engagement with patients and their families.
Time to attend Rounds and time to allow the processing of emotive issues from the Rounds were commented upon. The theme of a difficulty finding time to attend the Rounds was supported by a theme identified by Chadwick et al. (2016) who found that professionals felt Rounds would be improved if more individuals and a wider variety of teams could attend. A subtheme of this was also that professionals felt there was not time to process the emotional content of Rounds before returning to their shift. This theme has support from  who found that staff engaged in further discussions with colleagues upon returning to shift which they termed 'Mini Schwartz Rounds'. It was felt this was helpful in processing the stories and emotions generated by Rounds and provided closure to these experiences.
The final theme of lack of confidence in speaking in front of colleagues and fears of negative evaluation appears to be a unique theme which is unsupported by previous qualitative analyses of Schwartz Rounds. Professionals feared negative evaluation and interpretation of their emotional reactions, in particular the expression of anger and frustration with patients which was felt to be unprofessional and in conflict with their caring intentions. Professionals also feared appearing weak for expressing emotion and exposing vulnerabilities, although sharing vulnerabilities was also seen as beneficial in this study and by .

CONCLUSION
This study offers a rare mixed-method evaluation of the Schwartz Round approach in a mental healthcare setting and a long-term follow-up of 6 years. The Rounds were rated as helpful and were valued because of the opportunity to express emotionin particular negative emotions towards patients that conflicted with mental health professionals duty of care and professionalismand to share experiences and feel validated and supported by colleagues. From these encouraging findings, the researchers advocate the use of Schwartz Rounds in healthcare settings but also mental healthcare settings where compassion fatigue and emotional burnout might be mitigated by Round attendance. Feedback from attendees also suggests that regular Rounds offering greater continuity and connecting to supervision and lessons learnt could have an impact beyond staff well-being and into clinical practice.

RELEVANCE FOR CLINICAL PRACTICE
The Schwartz Rounds were rated as helpful and were valued for their staff well-being benefits by health professionals working within a mental healthcare setting. The UK Government has set targets and dedicated funding for increasing staff in priority areas such as mental health. However, with rates of staff attrition (Limb, 2017) and sickness due to stress increasing, it is clear that the burden on professionals' well-being and the burden on the quality of patient care need to be addressed with ongoing interventions which support emotional literacy, emotional sharing, and compassion. The Schwartz Rounds may offer the regular safe forum in which to progress towards this solution.