In 2009 when I was invited to become the facilitator of Schwartz Rounds at the Royal Free Hospital in London I felt I had a real and exciting chance to bring two strands of my life, and my work together. I’d long been interested in storytelling. My first degree was in English literature, and I loved writing. I also loved being a psychologist and I had often thought about trying to write creatively about the experience of having this role in a hectic organisation, sitting on the blurred interface between professional and personal experience, wondering about the similarities and differences between “patients “and staff. I had had “True Tales of Organisational Life” as a possible title in my mind for this story, for a number of years before I began my work on Rounds.
At the time I started my work on Schwartz Rounds, I had been working at the Royal Free for ten years providing psychology services for the staff. The post was innovative at the time as it was 50% clinical and 50% organisational. Being positioned in this way provided a fascinating insight into organisational life. However it was often a difficult place to sit. For who was the client? The individual or the organisation? What was my role and how legitimate was it really? How could I make sense of the tension I experienced sometimes, between how an individual or the organisation saw an experience, and hoped for change, and how I understood it? Was it possible to communicate this in a helpful way? And what would I do with stories of extreme distress or risk or error?
It took some time to become clear about positioning, and to learn how to understand and best respond to the anxieties that the role was asked (both consciously and unconsciously) to carry. Making sense of the tension, stress, conflicts, and exhaustion I experienced, when individual and organisational realities seemed incompatible and my work felt impossible, helped me to learn and understand more about complexity, and about the possibilities for interventions. Sometimes this learning occurred through my own painful experiences of organisational life.
Learning to disentangle my individual anxieties from the organisational anxieties within the challenges I was posed, taught me the importance of productive safe spaces. Without having them for myself I think now that I would have become unable to work – and sometimes that happened. But managing the tension I experienced in resisting the role of “adjudicator” or “corrective” or “remover (of distress or error or vulnerability) and staying as creatively neutral as possible was what eventually formed me, and came to inform the work which I did. This also influenced my other work as an organisational consultant, trainer and facilitator.
I became interested in the importance of creativity in developing safe spaces within organisational life where development and integration could occur, and realistic change could be considered. I developed this approach in my private work and I learnt to see the role of psychologist as both a translator and a container, helping individuals and organisations to digest, carry and sometimes simply witness the pain and the pleasure implicit in their work, and in its often troubled contexts.
And there was no doubt in my mind about the painful experiences that the staff who came to see me were withstanding, absorbing, or trying to reject. They were real and palpable, and harmful, not just for the individuals who brought me stories but often for those in their personal life too. Sometimes this harm was an invisible thread, unspoken, apparent because of absences in personal lives or lack of time for, or enjoyment in, life outside work. Some of these painful experiences seemed to be products of difficult organisational and team contexts; others were the product of the very real emotional challenges of healthcare.
The work is creative, rewarding, and meaningful for sure, but with huge potential for exposure to trauma and loss. It was interesting how little attention was paid to this and to the emotional impact of the work. It seemed easier to reject oneself than accept that painful, unwanted emotions may be being produced by the work rather than being a symptom of failure, incompetence, weakness or innate “badness”.
What was also worryingly invisible was the way in which the containment that can be offered by healthcare organisations has been dangerously eroded and diminished by the turbulent contexts of healthcare now within which organisations themselves, are fighting for survival. This leaves staff with a high price to pay. Individual explanations for difficulty are still however the default. So many people whom I saw for therapy came with the illusion that everyone else was doing so much better than them and their distress, and difficulty coping, was “their fault”.
Schwartz Rounds seemed to provide a real opportunity to tell stories to demonstrate that this isn’t true. Everyone struggles sometimes, healthcare work and its contexts can be tough, and both individuals and organisations have responsibilities with regard to minimising the impact of both, on staff and their patients. Work on Rounds provided me with an opportunity to integrate the experiences described above and to develop my ideas and practice.
It seemed to me that the opportunity that Rounds provided of using story – real stories – could allow a slow process of the witnessing of emerging meaning to begin. For who will listen to a psychologist tell them that is important to pay attention to the emotional dimensions of the work ? No one. That is not the language that is usually spoken in settings that demand robustness and reward competition and the ability to survive.
But narrative is irresistible and compelling, and a repetitive storytelling space allows the real and often hidden experiences of healthcare staff to become visible – the rewards, the cost, the values, the motivations, the shocking and beautiful things that are seen, and the variety of different experiences. Having four storytellers on a panel talking about the impact of the same case instantly conveys the differences created by variations in experience due to age, gender, ethnicity, place in hierarchy, level of experience, emotional intelligence, resilience etc. etc. Suddenly complexity becomes visible.
Facilitating Rounds in order to resist the pull towards action and problem solving creates an opportunity for complexity to be witnessed and considered or at least suggests this possibility. Repeating this experience at regular intervals allows for this process to become cumulative with hopefully a deepening of individual and organisational understanding, and the creation of a sustaining community.
When we brought Rounds to the UK we had no idea how they would be received. How significant would a different culture be? Setting up the first Round at the Royal Free was a huge step in the dark – like holding a party that you weren’t sure anyone would come to. AND you had persuaded your Chief Executive and other powerful people that it was a good idea so they would be there to see the no-shows. Oh, and the stumbling facilitation, because we had to learn in public by simply getting on and doing them. No one had facilitated Rounds in the UK before. But what we learnt straight away was that people were hungry for a space like this.
We quickly discovered that they would participate freely in a way that seemed to break the rules of organisational life and this gave us the courage to continue. Rounds were taken up keenly and enthusiastically and from the beginning were used productively. The hopes that I had of using this space to surface the dilemmas and experiences, with which individual clients and teams were grappling in private, suddenly seemed realisable. The possibility of crafting private stories for a public telling became real. The symbolic as well as actual possibilities of this space were apparent.
And once I began working nationally, developing and facilitating the training for Schwartz round facilitators, I had the same experience. People were hungry for creative spaces. Storytelling is irresistible. Well-crafted and well-held stories are compelling. Provided with containing and safe conditions, people are keen to tell their story – to hand their successes and their traumas over to the group to share, to jointly re-establish the fact that their work is meaningful and important and life enhancing – despite the many experiences that tend to obscure or erode this knowledge in organisational life today.
Participants on the courses surprised us with their willingness, and their need to reveal and explore the personal experiences within in their professional roles and the ways in which they had reconciled conflicts between the two (or not). I came to believe that many people wanted to work on this programme because of the opportunity for creativity that it allowed them, and to sense that this was an antidote to current culture. I grew convinced that our role must be to help them to develop both their skills and their ability to position this work effectively, in order to sustain themselves, and to ensure that the storytelling which they enabled was safe, and productive.
My book, True Tales of Organisational Life, tells the story of this work. It describes the links between evolving the role of the psychologist, positioning it and further developing it, and the development and implementation of a range of interventions. This is used to inform my understanding of implementing Rounds. So the implementation story is told in two ways. Firstly the story of bringing Rounds to the UK in order to be responsive to a different national culture is told. The idea of simply creating a space and then staying sensitive and responsive to what emerges, is proposed and explored in this part of the book. This is the broad-brush picture of the national experience, which also describes how in my work I conceptualised and developed Rounds’ implementation from a psychological perspective. Secondly, the story of establishing Rounds at the Royal Free is told. Here the focus is on the process of crafting stories and using psychological understanding to attend to, and understand, the process of safely bringing private experience into a public setting for the benefit of both the storyteller and the group – and possibly the organisation.
In the beginning I thought it would be a straightforward psychology book. As I wrote I found myself drawing from literature, and also wondered about the arena of performance and what light it could throw on the work I was engaged in. I considered ways to link the interventions to this idea. The idea of a public and a private persona, the creation of bridges between the two, and the exploration of the tension between the need to project presence and confidence, while appreciating the benefits of silence, stillness and owning vulnerability seemed fruitful ideas to reference.
I had seen the value of exploring this in the therapeutic and coaching work I did. I became fascinated by a consideration of the relationship between professional acts and their personal impacts and costs, which are mostly kept private and hidden. I also became convinced of the power of narrative to create permission for different conversations, and of the vital important of skilful facilitation to ensure that organisational rules could be safely disbanded and then re-established, at the beginning and at the end, of the unique one hour space.
I don’t remember now how I thought the book would evolve but I found myself needing to write it as a story and this seemed the most natural way to proceed. The process of writing the book itself became the story of my emerging understanding of these issues, and of the processes at work at many levels in psychological interventions. I repeatedly found that literature provided an accessible short-cut to psychological theory – an elegant and brief way to make a point or suggest a possibility.
I didn’t fully intend to write a book with an arc of “come with me while I show you what we did” but this is what happened. And so I realised that the only way to finish the book was with a collection of the stories themselves. And Royal Free staff generously allowed me to tell their stories, some of which they had brought to Rounds. There were of course confidentiality issues and it seemed that among other things, a way of managing this was to tell the stories through the lens of the impact they had on me. This also modelled the process I was trying to describe. “Let the stories do the talking” – was what the book was telling me, and the more I paid attention to this and listened to the stories the more important it seemed to be to allow them to push through. “Stand at the edge of the stage and let the stories speak “ – this is what I try to do when I facilitate a Round and this is what I came to aim for in the book.
So at another level the book is also about emergence. The emergence of meaning and of form, both in writing, and when bringing an intervention into a new setting. The emergence of understanding about the subtle process of shifting between disconnection and integration that health care work necessitates, in order for the flow of work to be achieved, and for patients to be cared for compassionately with the right balance of intimacy and objectivity. The emergence of clarity about what needs to be paid attention to and what must be left unsaid in order for movement of work and the business of the hospital to continue. The final section, “Untold Stories and Unfinished Business”, is a reflection on this, a consideration of where unattended experiences might go – and how and where they can be safely acknowledged. It suggests the symbolic importance of stories in simply reflecting experience and carrying our need for resolution, even if it sometimes cannot be achieved.
The process of writing mirrored the process I was engaged in in the work – creating a space in which connections could be made but only when it is safe and fruitful to connect them, and allowing form to be productively seen. I am not sure how fully conscious I was of all of this at the time I was doing the work. The process of writing the book helped to further clarify my understanding of what I had being doing and why.
Flannery O’ Connor has said that “I have to write to discover what I am doing. Like the old lady, I don’t know so well what I think until I see what I say; then I have to say it again.” Something similar happened to me in the process of writing the book. I became clearer as I wrote and meaning emerged. I am not sure now if it’s the book I originally thought I would write but it’s the book that arrived. The form has surprised me and the process has exhilarated me, and in the end I’ve said everything I needed and wanted to say (for now!). It’s a book I have been carrying around for ten years inside me, and I am so glad its finally seeing the light of day. I hope you enjoy reading it.
Barbara-Anne Wren is a psychologist and organisational consultant. While developing staff psychology services at the Royal Free she led on the successful piloting of the first of the two UK Schwartz Rounds. As Chair of the UK National Network of Practitioner Occupational Health Psychologists she has worked both nationally and internationally to develop theory and practice to improve staff experience in healthcare settings. Her book, True Tales of Organisational Life, has recently been published by Karnac.