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

Objectives (i) To synthesise the evidence-base for Schwartz Center Rounds (Rounds) to assess any impact on healthcare staff and identify key features; (ii) to scope evidence for interventions with similar aims, and compare effectiveness and key features to Rounds. Design Systematic review of Rounds literature; scoping reviews of comparator interventions (action learning sets; after action reviews; Balint groups; caregiver support programme; clinical supervision; critical incident stress debriefing; mindfulness-based stress reduction; peer-supported storytelling; psychosocial intervention training; reflective practice groups; resilience training). Data sources PsychINFO, CINAHL, MEDLINE and EMBASE, internet search engines; consultation with experts. Eligibility criteria Empirical evaluations (qualitative or quantitative); any healthcare staff in any healthcare setting; published in English. Results The overall evidence base for Rounds is limited. We developed a composite definition to aid comparison with other interventions from 41 documents containing a definition of Rounds. Twelve (10 studies) were empirical evaluations. All were of low/moderate quality (weak study designs including lack of control groups). Findings showed the value of Rounds to attenders, with a self-reported positive impact on individuals, their relationships with colleagues and patients and wider cultural changes. The evidence for the comparative interventions was scant and also low/moderate quality. Some features of Rounds were shared by other interventions, but Rounds offer unique features including being open to all staff and having no expectation for verbal contribution by attenders. Conclusions Evidence of effectiveness for all interventions considered here remains limited. Methods that enable identification of core features related to effectiveness are needed to optimise benefit for individual staff members and organisations as a whole. A systems approach conceptualising workplace well-being arising from both individual and environmental/structural factors, and comprising interventions both for assessing and improving the well-being of healthcare staff, is required. Schwartz Rounds could be considered as one strategy to enhance staff well-being.


Introduction
In this paper, we report the systematic review of evidence regarding Schwartz Center Rounds® (Rounds) and conduct a comparative analysis to eleven interventions also broadly aimed at supporting healthcare staff with the emotional challenges of their work. In doing so, we define Rounds from the literature and discuss the future potential use of interventions to support staff with the emotional challenges of providing healthcare. Healthcare providers are amongst the largest employers in many countries worldwide. For example, the UK NHS employs 1.5 million staff, [1] and in 2014 there were approximately 1.8 million physicians, [2] and 3.4 million nurses [3] across the EU. Provision of healthcare relies upon both clinical and non-clinical staff (e.g. managers, administrators, porters/orderlies, caterers, and domestic staff) all of whom may be impacted by the emotional challenges they face in their interactions with the patients and families they come across in day to day life.
Numerous publications have highlighted the high prevalence of psychological morbidity amongst healthcare staff in both clinical and non-clinical roles, and in many different countries worldwide. [4][5][6][7][8][9][10] Indeed, studies have typically reported between a quarter to a third of healthcare staff to have levels of psychological distress indicative of the need for clinical intervention, and in the UK mental health reasons explain a third of all NHS sickness absence, costing approximately £1bn (of the total £2.4bn cost of sickness absence in 2015). [11] Together with the clear consequences of this for their wellbeing and quality of life, and impact on their families, there is now increasing recognition of the link between the wellbeing of healthcare staff and quality of patient care (in relation to both patient experience, and clinical outcomes). [12][13][14][15]  Consequently, the wellbeing of healthcare staff is high on the agenda of healthcare organisations in the UK and worldwide. [16][17][18][19][20][21] In the UK, NICE guidance published in 2009 recommended that organisations take a strategic approach to tackling staff wellbeing, encompassing approaches that focus on both prevention and treatment, and that include interventions for individuals as well as "organisation-wide approaches that encompass all employees". [22] However, the reviews underpinning this guidance highlighted the poor quality of evidence overall and in particular the limited evidence on organisation-wide policies or approaches, with the strongest evidence in relation to interventions aimed at stress management for individuals. [22] Schwartz Rounds are a rare example of an organisation-wide intervention that has seen rapid spread across healthcare organisations in the UK. [23] Rounds originated in the U.S. where they now run in over 430 organisations. After a pilot introduction to two UK hospitals in 2009, they now run in over 170 UK health and social care organisations (hospitals, hospices, community settings). They were developed to support healthcare staff to deliver compassionate care by providing a safe space where staff could openly share and reflect on the emotional, social and ethical challenges faced at work. The premise is that caregivers will be more able to make personal connections with colleagues and patients if they have insight into their own responses and feelings. Their rapid adoption in the UK was despite a limited evidence base, though attendance at Rounds was reported to be associated with improved compassion for patients, better teamwork, and reduced stress in staff members, as well as having a positive impact on organisational culture. [24][25] Consequently, the National Institute for Health Research commissioned a national evaluation of Rounds that has recently concluded, [26] supporting these earlier findings and showing attendance at Rounds to be associated with a reduction in psychiatric morbidity. A key component of the evaluation,

Methods
The review of Schwartz Rounds literature followed PRISMA systematic literature review guidance where applicable.

Search strategy
The search strategies for the systematic review of Rounds literature involved: (i) a traditional database search (PsychINFO, CINAHL, MEDLINE, and EMBASE to give comprehensive coverage of medical, psychological, nursing and social sciences literature). As an example, the MEDLINE database search for Schwartz Rounds was: (Schwartz adj2 Round*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier] (ii) use of internet search engines; and (iii) consultation with F o r p e e r r e v i e w o n l y 7 experts. Inclusion criteria included having a health professional sample (either qualified or trainee) and empirically evaluate the intervention using qualitative and/or quantitative methods. The review excluded non-English language sources, unpublished dissertations/theses and any papers not accessible via the institution's online library, Google Scholar or directly from the journal website. All records were pooled together into a bibliographic database. First, records were screened to exclude duplicate entries. Second, the title and abstract of remaining records was reviewed for eligibility. All database searches were conducted between 14 th October 2014 and 5 th February 2015, though searches for Schwartz Rounds evaluations and consultation with experts continued until September 2017.

Data extraction and quality appraisal
Standard data items were extracted to describe included papers (e.g. citation, country, setting, population/sample, overall design etc) and the evaluation (e.g. length of evaluation; data collection method/s; outcome measures; key findings) using extraction sheets that were developed and piloted by all data extractors. In addition, items were developed that were specific to each intervention, for example, whether group or individual focused, size of group, length/number of sessions, content of sessions, whether facilitated or not (and if facilitated whether training/supervision was provided). Quality assessment of qualitative and quantitative primary studies was undertaken for each study using the tools developed by Jones et al [27] which include assessment of key criteria and then an overall rating (High -No or few flaws; Moderate -Some flaws; Low -Significant flaws). Mixed methods studies were, in addition, assessed against the six criteria for good reporting of mixed methods studies developed by O'Cathain et al [28]. Quality was rated low (<3 criteria were met); moderate (3)(4) or high (5+).

Synthesis
Thematic analysis of the types of outcomes reported resulted in the identification of three categories relating to: a) self; b) others (e.g. patients, colleagues); or c) wider organisation (e.g. changes to policies; organisational metrics such as safety or satisfaction). Findings are presented according to these three categories. Finally the overall quality of the evidence base for each intervention is described based on the range in quality for individual studies.

Constructing a composite definition of Schwartz Rounds
In order to determine the key features of Rounds for comparison with other interventions, we constructed a 'composite' definition based on descriptions used in Rounds literature. For this process, we included all literature (including non-empirical literature for example letters, editorials) providing it included a description of Rounds. Text describing Rounds (what they were and their aims, e.g. structure and purpose, as well as any text describing what they were 'not') was extracted from published accounts. The text was analysed thematically by four team members independently (CT, JM, ML, MH), core concepts were discussed and agreed, and a single definition was produced. The face validity of the definition was confirmed after review by study advisory and steering group members.

Scoping reviews of comparative interventions
The reviews of comparable interventions followed an interpretative scoping literature review methodology based on the framework outlined by Arksey and O'Malley[29]. The searching, data extraction and synthesis followed similar steps to the review of Schwartz Rounds literature (except where noted below) but instead of producing a detailed critique and review of individual studies they were instead aimed at producing a summary description of the evidence base in relation to size, scope and quality, and used to extract data relevant for the F o r p e e r r e v i e w o n l y 9 comparative analysis. For each intervention, the number/type of included papers was recorded, and each intervention was described in relation to its original format (e.g. number of participants, original setting and healthcare setting/s, and intended aims/outcomes); and the variability in its application within the literature (fidelity to original format). Main findings were examined across all interventions and analysed thematically (using the same categories as for Schwartz Rounds: self, others, organisation) to enable synthesis within, and comparison across, each intervention.

Identification of comparative interventions to include
We aimed to identify interventions that support health professionals with the emotional challenges of delivering patient care. Initially we identified aspects that were fundamental to Rounds, including providing an opportunity for reflection, disclosure, and offering psychological safety; and these informed choices regarding potential comparative interventions. Included interventions needed to focus on psychological (as opposed to physical) wellbeing of staff; be person-directed (versus work directed); and provide primarily emotional rather than cognitive/clinical support (thus for example excluding mortality/morbidity meetings which aim to provide lessons in terms of cognitive errors or systems issues). Although Rounds are a 'group' (rather than individual) intervention we chose not to limit comparative interventions by this characteristic, due to the importance of reflection and/or disclosure as a key potential mechanism in Rounds that is shared by other interventions that are not group-based. Potential comparative interventions were identified through published reviews of psychological/emotional support interventions for healthcare staff [30][31][32][33] and through consultation with steering and advisory group members (with expertise in Rounds/wellbeing interventions in healthcare). A total of 11 interventions were scoped: Action Learning Sets; After Action Reviews; Balint Groups; Caregiver Support

Comparative analysis to Schwartz Rounds
The composite definition of Rounds was disaggregated into its individual descriptive features which were extracted into a table, together with the features that were 'not' part of Rounds.
Further clarification was added for some descriptive features to ensure clarity of meaning (e.g. "reflection" became "provides an explicit opportunity for reflection"). The description of each comparative intervention was then reviewed by the research team and assessed in relation to whether or not it also provided each of the key features of Rounds. The face validity of the comparison between Rounds and other interventions was confirmed with study advisory and steering groups (with expertise in Rounds/healthcare staff wellbeing interventions).

Patient Involvement
We actively involved patients through membership of the Project Steering Group (PSG) which included two PPI representatives (Havi Carel, Christine Chapman) who had previously provided input to the original funding application. The PSG provided oversight to all aspects of the study, and alongside other group members our PPI representatives and Rounds staff members advised on design, inclusion of comparative interventions, and commented on the findings.

Key features of Rounds
Forty-three documents/sources were included in the review of descriptions of Rounds (Table   1) which allowed development of the definition. [24,25,. The majority (n=33) were non-empirical publications (e.g. commentaries, descriptive reports of a single Round). The thematic synthesis resulted in the production of the composite definition (supplementary file 1), a summary version is provided in Table 1.

Evidence base for Rounds: results from the systematic review
Twelve empirical evaluations of Rounds were included ( Table 2) arising from ten studies (four in the USA, six in the UK). Most were mixed methods evaluations, typically comprising attenders completing evaluation forms post-Round attendance, followed by interviews or focus groups (n=5), one mixed method study comprised case studies (observation/interviews) together with descriptive analysis of evaluation forms [75] and one that used both quantitative and qualitative methods to analyse evaluation forms. [76] Two were quantitative studies, and one qualitative study. Only one study included nonattenders [66] (Table 2).
Overall quality of the evidence-base was assessed to be low/moderate. Most studies had study designs prone to risk of bias (e.g. cross-sectional), used non-validated questionnaires (typically self-report views/satisfaction with Rounds and impact of attendance), and none of the quantitative evaluations had control group (non-attender) comparisons. Little information was provided on the samples/sampling frames in quantitative studies (e.g. in relation to breadth of professional group representation or role in Rounds), nor were findings analysed F o r p e e r r e v i e w o n l y 12 or presented in relation to such factors. In two studies that did report the characteristics of their quantitative sample, most were female and of white ethnicity, and nurses predominated (but neither study reported the seniority of nurse). [24,47] Findings from these studies included that Rounds are highly valued by attenders (though represented a small proportion of total staff). Most studies reported positive impact on 'self' (e.g. improved wellbeing, coping) [24][25]44,47,49,51,59,66,70,[75][76] and impact on patients (increased compassion, empathy), [24][25]51,59,66,70,[75][76] and colleagues (improved teamwork, compassion/empathy). [24][25]44,47,[50][51]59,66,[75][76] Six studies provide evidence of wider institutional impacts from interviews with attenders [24][25]44,51,66,[75][76] (Table 2). Three of the included studies were evaluations of Rounds adapted for educational purposes; [39,50,70] all reporting that Rounds were felt to be useful and that students gained knowledge/understanding about the emotional side of providing patient care.

Comparative interventions: results from the scoping reviews
Electronic searches for the 11 comparative interventions yielded a total of 1725 papers, of which 146 were included (ranging between one and 64 across interventions, Table 1, see supplementary file 3 for included references). A number of publications (n=253) were not obtainable due to being published in sources that no longer existed or not available through institutional subscription and internet searches. The largest evidence base was for clinical supervision (n=64) followed by Balint groups (n=26). Half of the studies were quantitative (n=74: RCT, observational, quasi experimental), 41 were qualitative (mixed designs, interviews, focus groups), 22 were mixed-methods, and nine were secondary studies (literature reviews). The literature was international with the majority of studies from the USA and the UK; other countries represented included Canada, Australia, Finland, Norway, Sweden, Croatia, Spain, Italy, Israel and South Africa. There was a distinct lack of studies from Asia, although that may be a reflection of the English language limit.
For most interventions, high-quality evidence was sparse. Populations for many of the interventions lacked diversity across health professions and settings, with many mostly nursing-focused. The aims of studies varied widely, with a few aimed at assessing efficacy or effectiveness but most were small-scale exploratory descriptive studies. The content and format of interventions (fidelity) was in most cases widely heterogeneous (and/or lacked detail), and consequently synthesis of findings is problematic. Most of the quantitative evaluations across all interventions relied upon weaker study designs (e.g. cross-sectional studies, post-intervention evaluations, lacking control comparisons), used non-probability sampling, had small samples likely to be underpowered, and used non-validated outcomes measures. Many qualitative studies also lacked clear reporting of aspects of rigour (e.g. limited reporting of member checking, deviant cases, reflexivity or evidence of data saturation). A summary of the evidence base for each intervention is provided in Supplementary file 2.

Synthesis
Most interventions presented evidence in relation to all three categories of outcomes ("self", "others" and "organisation"), though evidence for Resilience training, Mindfulness-based stress reduction and Reflective practice groups lacked inclusion of organisational outcomes.
All of the interventions had evidence of positive benefits to self (e.g. raised self-awareness, resilience, job satisfaction, empowerment, or overall wellbeing), and most provided some evidence of positive benefits to 'others'. Impact on patients included fostering of better provider-service user relationships, communication with and/or attitudes towards patients; At organisational-level, there was evidence from some interventions of association with improved practice, for example, reductions in unnecessary prescriptions, increased uptake of psychosocial support (Balint groups), reduction in task and coordination errors and increased uptake of post-fall huddles (After action reviews). Two interventions provided evidence of a positive impact on the workforce, including providing opportunities for mentoring and advice (Action learning sets) and improved staff retention (Clinical supervision).

Schwartz vs alternative interventions: comparative features
In comparison to the other interventions, Rounds offer a unique organisation-wide 'all-staff' forum to share stories about the emotional impact of providing patient care ( Arguably the closest types of interventions to Rounds are Balint groups (though rooted in uni-disciplinary primary care -physicians only-with closed membership), and Reflective practice groups (again generally closed membership and can be uni-disciplinary). In particular, both are ongoing group programmes in which challenging/rewarding experiences about delivering patient care are shared and discussions are facilitated, and both provide the opportunity to give and/or receive peer support in safe and confidential environments.
However, neither offers an organisation-wide opportunity for staff to attend, and both would have an expectation that members/attenders would contribute, whereas in Rounds attenders can choose to be silent listeners. Clinical supervision can also provide an opportunity to reflect on the emotional and ethical challenges of care without problem-solving/action planning -but unlike Rounds this usually occurs in a one to one situation, not group, and requires those being supervised to verbally contribute.

Discussion
Our work revealed a rich portfolio of available interventions to support staff with the emotional challenges of providing healthcare, each designed with different audiences and uses in mind. The evidence base regarding the effectiveness of these in the main remains weak, and more should be done to examine these more systematically. The studies reviewed here show some evidence of impact at different levels, and future work should seek to unpick which interventions work best, under which conditions and for which participants. To our knowledge this is the first comparative review of staff wellbeing interventions. Given the high rates of work-related stress and mental health issues amongst healthcare staff it is not acceptable for employers not to act, despite the weak evidence base for most approaches and interventions currently. Some staff groups have clinical supervision for example as an integral part of their work (mental health nurses; midwives; psychologists and social workers) whereas most doctors and nurses do not, and such staff often have little or no support with the emotional, social and ethical challenges of their work. Non-clinical staffwho may have much contact with patients and the events they encounter -are even more neglected in relation to the impact of delivering patient care on them. Selection of interventions should be based on a strategic approach that incorporates needs assessment, implementation of interventions/approaches and policies, and monitoring and review to determine the impact of these and refine/revise as necessary. There is a need for a range of approaches, not a one size fits all and our work does not suggest an either/ or approach for individual interventions. Rounds should not be seen as a replacement for or instead of clinical supervision (or other support/interventions) but could be offered to staff in addition.
Organisation-wide interventions are important to tackle workplace environmental/cultural factors that impact on wellbeing; to change attitudes and cultural norms around staff needing support as well as changing conversations in organisations around empathy, compassion and the support required to deliver these. Involving all employees may improve co-worker and supervisor support, which in turn can facilitate the development of a supportive workplace environment that reduces stress by improving attitudes and behaviours. [77] Compared to other interventions reviewed here, Rounds offer a unique organisation-wide "all staff" forum to reflect on the emotional impact of providing patient care, offering opportunities for staff to reflect, whether or not they choose to disclose/contribute to discussions, and accruing F o r p e e r r e v i e w o n l y 17 evidence suggests they may have many benefits to individuals, others (colleagues, patients) as well as wider organisational impacts. [26] Schwartz Rounds were originally conceived to meet a very specific identified need in healthcare: to support healthcare providers to be compassionate to patients through giving them insight into their own thoughts, feelings and behaviours. [26] In the UK the reasons given for adoption has been more about staff wellbeing, in line with evidence linking quality of patient care and experience with staff wellbeing. [13,23] Unlike many of the other interventions, they have a structured format, and are specifically not intended to be 'problemsolving'. In doing so they provide a 'counter-cultural' space that differs from the protocoldriven, outcome-orientated healthcare environment that values emotional stoicism: "Good Rounds shift an organisation and its workers away from their default position of urgent action, reaction and problem solving to an hour of stillness and slowness". [78,p41] Workforce interventions are often complex in nature, with many components and aims.
Their evaluation is thereby challenging, particularly with regard to attributing any changes to outcomes to the intervention as opposed to other causes within the organisation/system. The challenge of conducting a robust evaluations of organisation-wide interventions may be one explanation as to why such evidence is so sparse, [22] and for why there is instead a predominance of evidence regarding individually targeted interventions such as mindfulnessbased stress reduction. The application of new methodologies to address these challenges, such as realist evaluation, could enable a more robust understanding of how and why interventions work (or don't work), and has recently been applied in the first UK national evaluation of Schwartz Rounds. [26]

Limitations
The focus of this review on the evidence within healthcare staff meant that wider evidence for some interventions, beyond healthcare, was not considered. Also, the scoping methods applied to the comparable interventions inevitably means that some relevant evidence may have been omitted, though systematic electronic searching and consultation with experts aimed to minimise this risk. The rapid uptake of Rounds in the UK and need to contextualise them within staff wellbeing interventions, informed the design of this review. It was thereby a review that compared other interventions to the key features of Rounds, and did not thereby compare the key features of all the other interventions to each other, apart from by describing and synthesising their origins and evidence base.

Conclusion
Given the time and resources already committed to the interventions considered here, it is important to determine how best to identify the core features of effectiveness to optimise benefit for individual staff members and organisations as a whole. This work has now been undertaken for Schwartz Rounds using a realist-informed methodology that has identified the contextual factors that influence how and for whom Schwartz Rounds work, resulting in an organisational guide giving practical guidance and recommendations for organisations to maximise the effectiveness of Rounds in their organisations. [26,79] The application of similar methodologies for other interventions such as clinical supervision and Balint groups may further help ensure optimal outcomes. A systems approach as opposed to an individual approach to tackling staff wellbeing, in order to improve patient care, is required, comprising effective interventions for assessing and improving the wellbeing of healthcare staff.

Disclaimer:
The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the of the NHS, the NIHR, MRC, CCF, NETSCC, the HS&DR programme or the Department of Health.

Action learning sets (ALS)
Based on the concept of learning by reflection on (or reviewing) an experience, ALS usually contains 4-6 members (peers), with (or without) a "set advisor" to facilitate the process. ALS tend to be held intermittently, over a fixed programme cycle, and most participants contract with the facilitator for an agreed length of time. They are often closed groups. The set is not a team, as the focus is on actions of individuals, rather than shared work objectives. After action reviews (AAR) AARs are facilitated meetings, led by a senior member of staff, which aim to encourage active reflection on performance following a specific event. An AAR is a one-off meeting post-event and includes those who were involved with the event. The focus is on gaps in performance, and what could be done differently to enhance the outcome. AARs generally last about 30 minutes. Balint groups Balint groups meet every 1-4 weeks for 1-3 years. In the group, typically a doctor presents a troubling patient incident while the group listens. The goal of the presentation is to understand the issue from both the patient's and doctor's perspectives. The presentation can last about ten minutes, after which group members can ask clarifying questions. When all questions are exhausted, the group is invited to imagine themselves in the roles of the doctor and the patient. Caregiver support programme (CSP) Originally developed for mental health/learning disability care homes, CSP is described as a theorybased social support intervention aimed at increasing exchanges of social support and decreasing negative social interaction. It consists of six 4-5-hour group training sessions (ten managers, ten directcare staff and two facilitators) conducted over a nine week period. Strategies for improvement are drawn from the participants, based on their own experiences.

Clinical supervision
Clinical supervision originated in psychotherapy but also adopted by other disciplines, e.g. psychology/nursing. Process described as identifying a key issue, describing and defining it, undertaking a critical analysis, examining solutions, formulating an action plan, implementation and evaluation. It can take five different forms: one-to-one with expert from same discipline; one-to-one with supervisor from different discipline; one-to-one with colleague of similar expertise; supervision between groups of colleagues working together, and network supervision between people who do not usually work together.
307 252 (42,160,50) 9 64 Critical incident stress debriefing (CISD) In its original form, CISD is a single-issue debriefing session in a group context, led by an external team, following a traumatic event. CISD has seven phases: introduction, fact, thought, reaction, symptom, teaching, and re-entry. The debriefing session lasts for approximately 1.5-3 hours and takes place 24-72 hours after the traumatic event. The debriefing team is made up of a leader, a co-leader and a support, who work in conjunction to support the participants and to allow them to feel safe. 388 386 (62; 248; 76) 0 2

Mindfulnessbased stress reduction (MBSR)
The central principle of MBSR is mindfulness -being focused on and aware of the present moment with a non-judging attitude of acceptance. The original training module is eight weeks long with weekly sessions of 2.5 hours each. There is a seven hour session which takes place between weeks six and seven, and participants are asked to complete 45 minutes of daily formal mindful practice. They are taught a variety of mindful meditative practices, and there are group discussions about the application of these practices.

Peer-supported storytelling
Narrative storytelling is the act of an individual recounting verbally to one or more people a plausible account of an event, or series of events, possessing narrative truth for the teller. The story is arranged in a time sequence with plot, characters, context, intentionality, and perspective taking, possibly including the teller's actions, thoughts and feelings.

Psychosocial intervention training
Psychosocial intervention training involves cognitive behavioural approaches for managing symptoms, understanding symptom-related behaviour, relationship formation and helping service users to cope with symptoms. Teaching sessions are supplemented by small group supervision. Students are required to provide brief case study presentations about service users they are working with and receive feedback. Early courses were developed for nurses but quickly became multidisciplinary. 37 35 (6; 25; 4) 1 3

Reflective practice groups (RPG)
RPGs are facilitated groups of about ten healthcare professionals or students in which participants share and explore professional, clinical, ethical, and personal insights arising from their clinical work or training. RPGs are ongoing, convening regularly with each group lasting for about one hour. Discussion topics can either be raised by the facilitator or by the participants. The discussion is meant to be supportive as well as challenging, encouraging consideration of alternative viewpoints.

Resilience training
Resilience training is in part based on CBT theories and in its original form is a manualised intervention comprising 18 hours of workshops. The key characteristics include delivery to groups of practitioners who support one another and facilitated by an expert in personal and professional transition supervision. University of Pennsylvania well-known example consists of: learning ways to challenge unrealistic negative beliefs, strengthening problem solving, adopting assertiveness and negotiation skills, improving ability to deal with strong feelings, and learning how to tackle procrastination through use of decisionmaking and action-planning tools.

Overall
Found "dose" effect: more rounds attended, more impact they have.

Self
Attendance at Rounds associated with decreased stress and improved ability to cope with psychosocial demands/emotional difficulties at work.

Others
Rounds attendance led to increased patient interaction and teamwork scores. Interviews highlighted benefits including: getting to know colleagues and putting themselves in their shoes, and an improved sense of connection/shared purpose.  Lown & Manning, 2010 24 /Goodrich, 2011 51 ).
Overall 78% rated Rounds as excellent or exceptional Self -Focus groups: -Validation of experiences -Honesty, openness and vulnerability allowed others to see person on human level Others 87% gained insight into how others think/feel in caring for patients -Focus groups: fostered understanding of importance of non-clinical staff contribution -BUT non-attenders felt responsibility to smooth running of hospice and felt they contributed to wider team without needing to hear stark realities of care/work. Analysis controlled for whether it was first ever Round, length of time in role, session attended.

Self
-Emotional Labour: significantly reduced in staff where pre-round was their first round. -Self-reflection increased pre-post Compared SCR attenders with 10/11 interviewees who also completed ORES (did not attend Rounds). Found non-attenders had higher burnout and emotional labour, and more negative appraisal of organisation. Overall 93% of faculty and 83% of students rated the sessions as good, excellent or exceptional Self 80% of students and 96% of faculty believe students gained knowledge that will help them care for patients Others 75% of students and 96% of faculty believe the sessions will help students communicate better with patients and family members Moderate (lack of clarity regarding sampling/sample and measures)

Overall
Mean student ratings of a session were 3.5/5 (year 5) and 3.3/5 (year 6) -81% agreed/strongly agreed the presentation of cases was helpful -80% would attend a future Round -64% agreed Rounds should be integrated into the curriculum Focus group finding: Feelings about the Round (response to round, size of audience-large inhibiting, positive comparison to current reflective practice; post event peer discussions) Self -69% year 5 vs 87% year 6 students were worried about compassion fatigue or burnout -92% agreed/strongly agreed that they appreciated hearing stories demonstrating human side of medicine -Focus group finding: Psychological aspects of SCR (psychological pressures of medicine, how session encouraged positive processing of emotion, sharing personal stories between health professionals).

Overall
All aspects of Rounds highly rated by staff Self Improved reflection on own experiences Others Improved insight and understanding of others and their roles and support within the organization Most agreed that attended helped caring for patients and work with colleagues Organisation Reducing the effect of 'silo working' Staff were given a space where powerful emotions were accepted and responded to constructively Need to make Rounds more accessible to wider cross section of staff Other findings: -No significant differences between disciplines/staff groups in survey ratings    10 papers (8  studies): Yes as Rounds are licenced and have to be run according to a format subsequent to obtaining a licence.

Self
Wellbeing: reduced stress, emotional labour, and isolation at work Coping: improved ability to cope with emotional difficulties at work; confidence in handling sensitive issues Self-reflection: increased selfreflection/validation of experiences Knowledge: students report increased knowledge/understanding about emotional side of providing patient care. No variabilityhas only been used and evaluated in one study.

Self
Empowerment: measured ability to cope with common work problems and ability to influence decision making (non-significant improvement); Wellbeing: psychological wellbeing (nonsignificant improvement)

Others
Colleagues: greater supervisor support, less undermining, greater praise and feedback

6-7
Information sources 7 Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched.
6 Search 8 Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated.

6
Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis).

7
Data collection process 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators. 28-32 (Table 2) Results of individual studies 20 For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot.
28-32 (Table 2) Synthesis of results 21 Present results of each meta-analysis done, including confidence intervals and measures of consistency.
Narrative synthesis [11][12] Risk of bias across studies 22 Present results of any assessment of risk of bias across studies (see Item 15).
n/a DISCUSSION Summary of evidence 24 Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers).

15-16
Limitations 25 Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of identified research, reporting bias).

Article Summary: Strengths and limitations of this study
• This is the first systematic review of Schwartz Center Rounds®, a healthcare staff intervention from the US that has spread rapidly through UK healthcare organisations • Additional scoping reviews of 11 interventions with similar aims to support the wellbeing of healthcare staff, enables a novel comparative analysis to key features of Schwartz Rounds.
• This paper compares other staff wellbeing interventions to Rounds, thereby resulting in a focus on key features of Rounds; we did not explicitly draw out key features of other interventions or compare them against each other.
• The use of scoping reviews for comparator interventions, and exclusion of evidence in populations other than healthcare staff means that some evidence may have been omitted.
• The heterogeneity of study designs and outcomes, and weak study designs, means that findings are summarized narratively rather than using meta-analysis.

Introduction
In this paper, we report the systematic review of evidence regarding Schwartz Center Rounds® (Rounds) and conduct a comparative analysis to eleven interventions also broadly aimed at supporting healthcare staff with the emotional challenges of their work. In doing so, we define Rounds from the literature and discuss the future potential use of interventions to support staff with the emotional challenges of providing healthcare. Healthcare providers are amongst the largest employers in many countries worldwide. For example, the UK NHS . [11] Together with the clear consequences of this for their wellbeing and quality of life, and impact on their families, there is now increasing recognition of the link between the wellbeing of healthcare staff and quality of patient care (in relation to both patient experience, and clinical outcomes). [12][13][14][15]  Consequently, the wellbeing of healthcare staff is high on the agenda of healthcare organisations in the UK and worldwide. [16][17][18][19][20][21] In the UK, NICE guidance published in 2009 recommended that organisations take a strategic approach to tackling staff wellbeing, encompassing approaches that focus on both prevention and treatment, and that include interventions for individuals as well as "organisation-wide approaches that encompass all employees". [22] However, the reviews underpinning this guidance highlighted the poor quality of evidence overall and in particular the limited evidence on organisation-wide policies or approaches, with the strongest evidence in relation to interventions aimed at stress management for individuals. [22] Schwartz Rounds are a rare example of an organisation-wide intervention that has seen rapid spread across healthcare organisations in the UK. [23] Rounds originated in the U.S. where they now run in over 430 organisations. After a pilot introduction to two UK hospitals in 2009, they now run in over 170 UK health and social care organisations (hospitals, hospices, community settings). They were developed to support healthcare staff to deliver compassionate care by providing a safe space where staff could openly share and reflect on the emotional, social and ethical challenges faced at work. The premise is that caregivers will be more able to make personal connections with colleagues and patients if they have insight into their own responses and feelings. Their rapid adoption in the UK was despite a limited evidence base, though attendance at Rounds was reported to be associated with improved compassion for patients, better teamwork, and reduced stress in staff members, as well as having a positive impact on organisational culture. [24][25] Consequently, the National Institute for Health Research commissioned a national evaluation of Rounds that has recently concluded, [26] supporting these earlier findings and showing attendance at Rounds to be associated with a reduction in psychiatric morbidity. A key component of the evaluation,

Methods
The review of Schwartz Rounds literature followed PRISMA systematic literature review guidance where applicable.

Search strategy
The search strategies for the systematic review of Rounds

Data extraction and quality appraisal
Standard data items were extracted to describe included papers (e.g. citation, country, setting, population/sample, overall design etc) and the evaluation (e.g. length of evaluation; data collection method/s; outcome measures; key findings) using extraction sheets that were developed and piloted by all data extractors. In addition, items were developed that were specific to each intervention, for example, whether group or individual focused, size of group, length/number of sessions, content of sessions, whether facilitated or not (and if facilitated whether training/supervision was provided). Quality assessment of qualitative and quantitative primary studies was undertaken for each study using the tools developed by Jones et al [27] which include assessment of key criteria and then an overall rating (High -No or few flaws; Moderate -Some flaws; Low -Significant flaws). Mixed methods studies were, in addition, assessed against the six criteria for good reporting of mixed methods studies developed by O'Cathain et al [28]. Quality was rated low (<3 criteria were met); moderate (3)(4) or high (5+).

Synthesis
Thematic analysis of the types of outcomes reported resulted in the identification of three categories relating to: a) self; b) others (e.g. patients, colleagues); or c) wider organisation (e.g. changes to policies; organisational metrics such as safety or satisfaction). Findings are presented according to these three categories. Finally the overall quality of the evidence base for each intervention is described based on the range in quality for individual studies.

Constructing a composite definition of Schwartz Rounds
Whilst purpose, as well as any text describing what they were 'not') was extracted from published accounts. The text was analysed thematically by four team members independently (CT, JM, ML, MH), core concepts were discussed and agreed, and a single definition was produced.
The face validity of the definition was confirmed after review by study advisory and steering group members. The reviews of comparable interventions followed an interpretative scoping literature review methodology based on the framework outlined by Arksey and O'Malley[29]. The searching, data extraction and synthesis followed similar steps to the review of Schwartz Rounds literature (except where noted below) but instead of producing a detailed critique and review of individual studies they were instead aimed at producing a summary description of the evidence base in relation to size, scope and quality, and used to extract data relevant for the comparative analysis. For each intervention, the number/type of included papers was recorded, and each intervention was described in relation to its original format (e.g. number of participants, original setting and healthcare setting/s, and intended aims/outcomes); and the variability in its application within the literature (fidelity to original format). Main findings were examined across all interventions and analysed thematically (using the same categories as for Schwartz Rounds: self, others, organisation) to enable synthesis within, and comparison across, each intervention.

Identification of comparative interventions to include
We aimed to identify interventions that support health professionals with the emotional challenges of delivering patient care. Initially we identified aspects that were fundamental to Rounds, including providing an opportunity for reflection, disclosure, and offering psychological safety; and these informed choices regarding potential comparative interventions. Included interventions needed to focus on psychological (as opposed to physical) wellbeing of staff; be person-directed (versus work directed); and provide primarily emotional rather than cognitive/clinical support (thus for example excluding mortality/morbidity meetings which aim to provide lessons in terms of cognitive errors or systems issues). Although Rounds are a 'group' (rather than individual) intervention we chose not to limit comparative interventions by this characteristic, due to the importance of

Comparative analysis to Schwartz Rounds
The composite definition of Rounds was disaggregated into its individual descriptive features which were extracted into a table, together with the features that were 'not' part of Rounds.
Further clarification was added for some descriptive features to ensure clarity of meaning (e.g. "reflection" became "provides an explicit opportunity for reflection"). The description of each comparative intervention was then reviewed by the research team and assessed in relation to whether or not it also provided each of the key features of Rounds. The face validity of the comparison between Rounds and other interventions was confirmed with study advisory and steering groups (with expertise in Rounds/healthcare staff wellbeing interventions).

Patient Involvement
We actively involved patients through membership of the Project Steering Group (PSG) which included two Patient Public Involvement (PPI) representatives (Havi Carel, Christine Chapman) who had previously provided input to the original funding application. The PSG

Key features of Rounds
Forty-three documents/sources were included in the review of descriptions of Rounds (Table   1) which allowed development of the definition. [24,25,. The majority (n=33) were non-empirical publications (e.g. commentaries, descriptive reports of a single Round). The thematic synthesis resulted in the production of the composite definition (supplementary file 1), a summary version is provided in Table 1.

Evidence base for Rounds: results from the systematic review
Twelve empirical evaluations of Rounds were included ( Table 2) arising from ten studies (four in the USA, six in the UK). Most were mixed methods evaluations, typically comprising attenders completing evaluation forms post-Round attendance, followed by interviews or focus groups (n=5), one mixed method study comprised case studies (observation/interviews) together with descriptive analysis of evaluation forms [75] and one that used both quantitative and qualitative methods to analyse evaluation forms. [76] Two were quantitative studies, and one qualitative study. Only one study included nonattenders [66] (Table 2).
Overall quality of the evidence-base was assessed to be low/moderate. Most studies had study designs prone to risk of bias (e.g. cross-sectional), used non-validated questionnaires (typically self-report views/satisfaction with Rounds and impact of attendance), and none of the quantitative evaluations had control group (non-attender) comparisons. Little information was provided on the samples/sampling frames in quantitative studies (e.g. in relation to breadth of professional group representation or role in Rounds), nor were findings analysed or presented in relation to such factors. In two studies that did report the characteristics of their quantitative sample, most were female and of white ethnicity, and nurses predominated (but neither study reported the seniority of nurse). [24,47] Findings from these studies included that Rounds are highly valued by attenders (though represented a small proportion of total staff). Most studies reported positive impact on 'self' (e.g. improved wellbeing, coping) [24][25]44,47,49,51,59,66,70,[75][76] and impact on patients (increased compassion, empathy), [24][25]51,59,66,70,[75][76] and colleagues (improved teamwork, compassion/empathy). [24][25]44,47,[50][51]59,66,[75][76] Six studies provide evidence of wider institutional impacts from interviews with attenders [24][25]44,51,66,[75][76] ( Table 2). Three of the included studies were evaluations of Rounds adapted for educational purposes; [39,50,70] all reporting that Rounds were felt to be useful and that students gained knowledge/understanding about the emotional side of providing patient care.

Comparative interventions: results from the scoping reviews
Electronic searches for the 11 comparative interventions yielded a total of 1725 papers, of which 146 were included (ranging between one and 64 across interventions, Table 1, see

Synthesis
Most interventions presented evidence in relation to all three categories of outcomes ("self", "others" and "organisation"), though evidence for Resilience training, Mindfulness-based stress reduction and Reflective practice groups lacked inclusion of organisational outcomes.
All of the interventions had evidence of positive benefits to self (e.g. raised self-awareness, resilience, job satisfaction, empowerment, or overall wellbeing), and most provided some evidence of positive benefits to 'others'. Impact on patients included fostering of better provider-service user relationships, communication with and/or attitudes towards patients; and improved patient-centredness, knowledge of patients' suffering and empathy. Impact on colleagues, included associations with better teamwork, peer support and knowledge/understanding of colleagues.
At organisational-level, there was evidence from some interventions of association with improved practice, for example, reductions in unnecessary prescriptions, increased uptake of psychosocial support (Balint groups), reduction in task and coordination errors and increased uptake of post-fall huddles (After action reviews). Two interventions provided evidence of a positive impact on the workforce, including providing opportunities for mentoring and advice (Action learning sets) and improved staff retention (Clinical supervision).

Schwartz vs alternative interventions: comparative features
In comparison to the other interventions, Rounds offer a unique organisation-wide 'all-staff' forum to share stories about the emotional impact of providing patient care ( Arguably the closest types of interventions to Rounds are Balint groups (though rooted in uni-disciplinary primary care -physicians only-with closed membership), and Reflective practice groups (again generally closed membership and can be uni-disciplinary). In particular, both are ongoing group programmes in which challenging/rewarding experiences about delivering patient care are shared and discussions are facilitated, and both provide the opportunity to give and/or receive peer support in safe and confidential environments.
However, neither offers an organisation-wide opportunity for staff to attend, and both would have an expectation that members/attenders would contribute, whereas in Rounds attenders can choose to be silent listeners. Clinical supervision can also provide an opportunity to reflect on the emotional and ethical challenges of care without problem-solving/action planning -but unlike Rounds this usually occurs in a one to one situation, not group, and requires those being supervised to verbally contribute.  Organisation-wide interventions are important to tackle workplace environmental/cultural  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  the support required to deliver these. Involving all employees may improve co-worker and supervisor support, which in turn can facilitate the development of a supportive workplace environment that reduces stress by improving attitudes and behaviours. [77] Compared to other interventions reviewed here, Rounds offer a unique organisation-wide "all staff" forum to reflect on the emotional impact of providing patient care, offering opportunities for staff to reflect, whether or not they choose to disclose/contribute to discussions, and accruing evidence suggests they may have many benefits to individuals, others (colleagues, patients) as well as wider organisational impacts. [26] Schwartz Rounds were originally conceived to meet a very specific identified need in healthcare: to support healthcare providers to be compassionate to patients through giving them insight into their own thoughts, feelings and behaviours. [26] In the UK the reasons given for adoption has been more about staff wellbeing, in line with evidence linking quality of patient care and experience with staff wellbeing. [13,23] Unlike many of the other interventions, they have a structured format, and are specifically not intended to be 'problemsolving'. In doing so they provide a 'counter-cultural' space that differs from the protocoldriven, outcome-orientated healthcare environment that values emotional stoicism: "Good Rounds shift an organisation and its workers away from their default position of urgent action, reaction and problem solving to an hour of stillness and slowness". [78,p41] A key ingredient supporting Rounds to meet their intended aims is good facilitation, thus the role of the facilitator is key. Unlike the facilitation role in other interventions we reviewed, where there was often much variability in relation 'fidelity', in the UK, it is mandatory for Rounds facilitators to attend training provided by the Point of Care Foundation (PoCF, the UK  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   18 Licence holder for Schwartz Rounds), and they receive ongoing support from Schwartz mentors. It is recommended that there are at least two facilitators in each organisation, and the PoCF state that it helps if facilitators have experience of group work, and managing difficult emotions (many have psychology or social work backgrounds). In our national evaluation, we found despite most having these skills and background, they often shouldered the responsibility for Rounds on their own (some having only one facilitator too), which we found to impact negatively on their wellbeing, and on the sustainability of Rounds, recommending that a focus on facilitator support, and succession planning would be beneficial for Rounds [26,79] Workforce interventions are often complex in nature, with many components and aims.
Their evaluation is thereby challenging, particularly with regard to attributing any changes to outcomes to the intervention as opposed to other causes within the organisation/system. The challenge of conducting a robust evaluations of organisation-wide interventions may be one explanation as to why such evidence is so sparse, [22] and for why there is instead a predominance of evidence regarding individually targeted interventions such as mindfulnessbased stress reduction. The application of new methodologies to address these challenges, such as realist evaluation, could enable a more robust understanding of how and why interventions work (or don't work), and has recently been applied in the first UK national evaluation of Schwartz Rounds. [26] Limitations The focus of this review on the evidence within healthcare staff meant that wider evidence for some interventions, beyond healthcare, was not considered. Also, the scoping methods applied to the comparable interventions inevitably means that some relevant evidence may  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   19 have been omitted, though systematic electronic searching and consultation with experts aimed to minimise this risk. The rapid uptake of Rounds in the UK and need to contextualise them within staff wellbeing interventions, informed the design of this review. It was thereby a review that compared other interventions to the key features of Rounds, and did not thereby compare the key features of all the other interventions to each other, apart from by describing and synthesising their origins and evidence base.

Conclusion
Given the time and resources already committed to the interventions considered here, it is important to determine how best to identify the core features of effectiveness to optimise benefit for individual staff members and organisations as a whole. This work has now been undertaken for Schwartz Rounds using a realist-informed methodology that has identified the contextual factors that influence how and for whom Schwartz Rounds work, resulting in an organisational guide giving practical guidance and recommendations for organisations to maximise the effectiveness of Rounds in their organisations. [26,79] The application of similar methodologies for other interventions such as clinical supervision and Balint groups may further help ensure optimal outcomes. A systems approach as opposed to an individual approach to tackling staff wellbeing, in order to improve patient care, is required, comprising effective interventions for assessing and improving the wellbeing of healthcare staff.

Action learning sets (ALS)
Based on the concept of learning by reflection on (or reviewing) an experience, ALS usually contains 4-6 members (peers), with (or without) a "set advisor" to facilitate the process. ALS tend to be held intermittently, over a fixed programme cycle, and most participants contract with the facilitator for an agreed length of time. They are often closed groups. The set is not a team, as the focus is on actions of individuals, rather than shared work objectives. After action reviews (AAR) AARs are facilitated meetings, led by a senior member of staff, which aim to encourage active reflection on performance following a specific event. An AAR is a one-off meeting post-event and includes those who were involved with the event. The focus is on gaps in performance, and what could be done differently to enhance the outcome. AARs generally last about 30 minutes. Balint groups Balint groups meet every 1-4 weeks for 1-3 years. In the group, typically a doctor presents a troubling patient incident while the group listens. The goal of the presentation is to understand the issue from both the patient's and doctor's perspectives. The presentation can last about ten minutes, after which group members can ask clarifying questions. When all questions are exhausted, the group is invited to imagine themselves in the roles of the doctor and the patient. Caregiver support programme (CSP) Originally developed for mental health/learning disability care homes, CSP is described as a theorybased social support intervention aimed at increasing exchanges of social support and decreasing negative social interaction. It consists of six 4-5-hour group training sessions (ten managers, ten directcare staff and two facilitators) conducted over a nine week period. Strategies for improvement are drawn from the participants, based on their own experiences.

Clinical supervision
Clinical supervision originated in psychotherapy but also adopted by other disciplines, e.g. psychology/nursing. Process described as identifying a key issue, describing and defining it, undertaking a critical analysis, examining solutions, formulating an action plan, implementation and evaluation. It can take five different forms: one-to-one with expert from same discipline; one-to-one with supervisor from different discipline; one-to-one with colleague of similar expertise; supervision between groups of colleagues working together, and network supervision between people who do not usually work together.
307 252 (42,160,50) 9 64 Critical incident stress debriefing (CISD) In its original form, CISD is a single-issue debriefing session in a group context, led by an external team, following a traumatic event. CISD has seven phases: introduction, fact, thought, reaction, symptom, teaching, and re-entry. The debriefing session lasts for approximately 1.5-3 hours and takes place 24-72 hours after the traumatic event. The debriefing team is made up of a leader, a co-leader and a support, who work in conjunction to support the participants and to allow them to feel safe. 388 386 (62; 248; 76) 0 2

Mindfulnessbased stress reduction (MBSR)
The central principle of MBSR is mindfulness -being focused on and aware of the present moment with a non-judging attitude of acceptance. The original training module is eight weeks long with weekly sessions of 2.5 hours each. There is a seven hour session which takes place between weeks six and seven, and participants are asked to complete 45 minutes of daily formal mindful practice. They are taught a variety of mindful meditative practices, and there are group discussions about the application of these practices.

Peer-supported storytelling
Narrative storytelling is the act of an individual recounting verbally to one or more people a plausible account of an event, or series of events, possessing narrative truth for the teller. The story is arranged in a time sequence with plot, characters, context, intentionality, and perspective taking, possibly including the teller's actions, thoughts and feelings.

Psychosocial intervention training
Psychosocial intervention training involves cognitive behavioural approaches for managing symptoms, understanding symptom-related behaviour, relationship formation and helping service users to cope with symptoms. Teaching sessions are supplemented by small group supervision. Students are required to provide brief case study presentations about service users they are working with and receive feedback. Early courses were developed for nurses but quickly became multidisciplinary. 37 35 (6; 25; 4) 1 3

Reflective practice groups (RPG)
RPGs are facilitated groups of about ten healthcare professionals or students in which participants share and explore professional, clinical, ethical, and personal insights arising from their clinical work or training. RPGs are ongoing, convening regularly with each group lasting for about one hour. Discussion topics can either be raised by the facilitator or by the participants. The discussion is meant to be supportive as well as challenging, encouraging consideration of alternative viewpoints.

Resilience training
Resilience training is in part based on CBT theories and in its original form is a manualised intervention comprising 18 hours of workshops. The key characteristics include delivery to groups of practitioners who support one another and facilitated by an expert in personal and professional transition supervision. University of Pennsylvania well-known example consists of: learning ways to challenge unrealistic negative beliefs, strengthening problem solving, adopting assertiveness and negotiation skills, improving ability to deal with strong feelings, and learning how to tackle procrastination through use of decisionmaking and action-planning tools.

Overall
Found "dose" effect: more rounds attended, more impact they have.

Self
Attendance at Rounds associated with decreased stress and improved ability to cope with psychosocial demands/emotional difficulties at work.

Others
Rounds attendance led to increased patient interaction and teamwork scores. Interviews highlighted benefits including: getting to know colleagues and putting themselves in their shoes, and an improved sense of connection/shared purpose.  Lown & Manning, 201024 /Goodrich, 2011.
Overall 78% rated Rounds as excellent or exceptional Self -Focus groups: -Validation of experiences -Honesty, openness and vulnerability allowed others to see person on human level Others 87% gained insight into how others think/feel in caring for patients -Focus groups: fostered understanding of importance of non-clinical staff contribution -BUT non-attenders felt responsibility to smooth running of hospice and felt they contributed to wider team without needing to hear stark realities of care/work. Analysis controlled for whether it was first ever Round, length of time in role, session attended.

Self
-Emotional Labour: significantly reduced in staff where pre-round was their first round. -Self-reflection increased pre-post Compared SCR attenders with 10/11 interviewees who also completed ORES (did not attend Rounds). Found non-attenders had higher burnout and emotional labour, and more negative appraisal of organisation. Overall 93% of faculty and 83% of students rated the sessions as good, excellent or exceptional Self 80% of students and 96% of faculty believe students gained knowledge that will help them care for patients Others 75% of students and 96% of faculty believe the sessions will help students communicate better with patients and family members Moderate (lack of clarity regarding sampling/sample and measures)

Overall
Mean student ratings of a session were 3.5/5 (year 5) and 3.3/5 (year 6) -81% agreed/strongly agreed the presentation of cases was helpful -80% would attend a future Round -64% agreed Rounds should be integrated into the curriculum Focus group finding: Feelings about the Round (response to round, size of audience-large inhibiting, positive comparison to current reflective practice; post event peer discussions) Self -69% year 5 vs 87% year 6 students were worried about compassion fatigue or burnout -92% agreed/strongly agreed that they appreciated hearing stories demonstrating human side of medicine -Focus group finding: Psychological aspects of SCR (psychological pressures of medicine, how session encouraged positive processing of emotion, sharing personal stories between health professionals).

Self
Empowerment: measured ability to cope with common work problems and ability to influence decision making (nonsignificant improvement); Wellbeing: psychological wellbeing (non-significant improvement)

Others
Colleagues: greater supervisor support, less undermining, greater praise and feedback

Mindfulnessbased Stress Reduction
Acute and community settings, with doctors and nurses (qualified and intraining) and a range of allied health professions. Empowerment: improved knowledge of, and attitude towards, mental illness and psychosocial approaches but lacking a power calculation and not clearly accounting for confounding variables.

Reflective Practice Groups
Clinical psychology, psychotherapy, nursing, medicine, midwifery and radiology. 8 papers: -3 quantitative -3 qualitative -2 mixed methods All described as facilitated groups that explore practice related issues. Can last between 45-90 minutes; held weekly, fortnightly or monthly; group sizes varied from six to 20 attendees, with one or two facilitators.

Self
Awareness: improved self-awareness and clinical insight Empowerment: increased confidence and capacity for reflection; better understanding of psychological ideas Wellbeing: increased ability to cope with stress

4-6
Objectives 4 Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).

METHODS
Protocol and registration 5 Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration information including registration number.
n/a Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rationale.

6-7
Information sources 7 Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched. 6 Search 8 Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated.

6
Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis).

7
Data collection process 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators. 7 Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.
n/a Risk of bias in individual studies 12 Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis. 28-32 (Table 2) Risk of bias within studies 19 Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12). (Table 2) Results of individual studies 20 For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot.

28-32
28-32 (Table 2) Synthesis of results 21 Present results of each meta-analysis done, including confidence intervals and measures of consistency.
Narrative synthesis [11][12] Risk of bias across studies 22 Present results of any assessment of risk of bias across studies (see Item 15).
n/a DISCUSSION Summary of evidence 24 Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers).

15-16
Limitations 25 Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of identified research, reporting bias).