Debriefing: An Expert Panel's How-to Guide

Helping clinicians debrief themselves: a simple how-to guide

The operating theatre is a dynamic and challenging environment where effective teamwork is essential. Routine clinical debriefings, which involve brief reflections on collaboration to identify successes and areas for improvement, have proved to enhance teamwork, particularly in the operating theatre. However, barriers such as time constraints, conflicting priorities, and a lack of standardised debriefing processes hinder their regular use. Implementation of TALK©, a voluntary self-debriefing method, showed significant improvements in debriefing performance and integration of debriefing into routine practice, although long-term consistency remains a challenge.

A systematic scoping review of group reflection in medical education

BACKGROUND

Reviewing experiences and recognizing the impact of personal and professional views and emotions upon conduct shapes a physician's professional and personal development, molding their professional identity formation (PIF). Poor appreciation on the role of reflection, shortages in trained tutors and inadequate 'protected time' for reflections in packed medical curricula has hindered its integration into medical education. Group reflection could be a viable alternative to individual reflections; however, this nascent practice requires further study.

METHODS

A Systematic Evidence Based Approach guided Systematic Scoping Review (SSR in SEBA) was adopted to guide and structure a review of group reflections in medical education. Independent searches of articles published between 1st January 2000 and 30th June 2022 in bibliographic and grey literature databases were carried out. Included articles were analysed separately using thematic and content analysis, and combined into categories and themes. The themes/categories created were compared with the tabulated summaries of included articles to create domains that framed the synthesis of the discussion.

RESULTS

1141 abstracts were reviewed, 193 full-text articles were appraised and 66 articles were included and the domains identified were theories; indications; types; structure; and benefits and challenges of group reflections.

CONCLUSIONS

Scaffolded by current approaches to individual reflections and theories and inculcated with nuanced adaptations from other medical practices, this SSR in SEBA suggests that structured group reflections may fill current gaps in training. However, design and assessment of the evidence-based structuring of group reflections proposed here must be the focus of future study.

Development, Implementation, and Provider Perception of Standardized Critical Event Debriefing in a Pediatric Emergency Department

OBJECTIVE

Hot debriefings are communications among team members occurring shortly after an event. They have been shown to improve team performance and communication. Best practice guidelines encourage hot debriefings, but these are often not routinely performed. We aim to describe the development and implementation of a multidisciplinary hot debriefing process in our pediatric emergency department (ED), and its impact on hot debriefing completion and provider perceptions.

METHODS

An internal tool and protocol for hot debriefings were developed by integrating responses from a survey of those who work in the ED at our institution and previously published debriefing tools. Charge nurses and pediatric emergency medicine physicians were trained to lead hot debriefings. Surveys on the perception of hot debriefings were administered before and 6 months postimplementation.Twelve-month baseline data were established by asking physicians who cared for patients who died in the ED or within 48 hours of admission to recall debrief completion. Debriefs were then prospectively tracked for 6 months postimplementation.

RESULTS

Debrief completion for patient deaths in the ED or within 48 hours of admission increased from 23% (5/22) to 75% (12/16) ( P < 0.001). When assessing just those deaths within the ED, this number increased from 31% (5/16) to 85% (11/13) ( P < 0.001).There were 98 responses to a baseline survey (response rate, 60.5%). Most who were surveyed felt that debriefs rarely occurred, preferred hot debriefings to cold debriefings, and felt that more hot debriefings should occur. Perceived barriers included lack of time, interest, protocol, trained facilitators, departmental support, and inability to gather the team.There were 88 responses to a postintervention survey (response rate, 56.8%), 50 of which had participated in a debrief and were included in analysis. Those surveyed felt that debriefs occurred more often and were more often valuable. Most perceived that barriers were significantly reduced. Most respondents felt that hot debriefs helped address systems issues and improved performance.

CONCLUSIONS

Implementation of a protocol for physician or charge nurse-led hot debriefings in our pediatric ED resulted in increased completion, perceived barrier reduction, and a uniform approach to address identified issues. Pediatric EDs should consider adoption of a hot debriefing protocol given these benefits.

Applying after-action reviews to child and family teams to improve mental health service linkage within child welfare services: a study protocol

BACKGROUND

Half of child-welfare-involved children and adolescents meet the criteria for at least one mental health diagnosis. This project proposes to improve successful mental health service linkage in child welfare services (CWS) by adapting and testing the after-action review (AAR) team effectiveness intervention to augment the child and family team (CFT) services' intervention. Despite being both required and a collaborative approach to service planning, CFT meetings are implemented with questionable fidelity and consistency, rarely including the voice of children and families as intended.

METHODS

Using a parallel group trial design, with non-equivalent comparison groups, and qualitative and quantitative methodology, this study will tailor and assess the impact of the AAR on enhancing CFT outcomes. The authors will conduct a qualitative needs assessment targeting the ongoing implementation of the CFT services intervention in a large, publicly funded, CWS system. A qualitative inquiry consisting of interviews and focus groups with key stakeholders will result in the preparation of an action plan to address identified gaps between the current and desired CFT services intervention outcomes. The AAR implementation strategy will be adapted and tailored to address the CFT services' intervention needs. To test the effectiveness of the AAR on improving outcomes associated with the CFT services intervention, we will utilize blocked randomization of four CWS caseworkers from two CWS system regions to either the intervention condition (CFT + AAR) or standard implementation (CFT as usual). The authors will collect data from the CWS caseworkers and additional CFT members via web-based surveys. Mechanisms of the AAR team effectiveness intervention for CFT implementation will be assessed.

DISCUSSION

By inclusion of child and family voice, the AAR-enhanced CFT should lead to increased fidelity to the CFT intervention and greater levels of parental satisfaction with the service and shared decision-making, thus resulting in enhanced follow-through with service plans and linkage to mental health treatment services for children. The knowledge gained by this randomized clinical trial has the potential to benefit service delivery and integration for CWS leaders, caseworkers, formal and informal CFT member support persons, parents/caregivers, and children with open cases. Improving intervention effectiveness, both at the system and family levels, is crucial for practice efficiencies and improved child and family outcomes.

TRIAL REGISTRATION

NCT05629013. Approval date: November 28, 2022 (version 1).

TRIAL SPONSOR

University of California, San Diego.

RESPONSIBLE PARTY

Danielle Fettes.

Helping healthcare teams to debrief effectively: associations of debriefers' actions and participants' reflections during team debriefings

BACKGROUND

Debriefings help teams learn quickly and treat patients safely. However, many clinicians and educators report to struggle with leading debriefings. Little empirical knowledge on optimal debriefing processes is available. The aim of the study was to evaluate the potential of specific types of debriefer communication to trigger participants' reflection in debriefings.

METHODS

In this prospective observational, microanalytic interaction analysis study, we observed clinicians while they participated in healthcare team debriefings following three high-risk anaesthetic scenarios during simulation-based team training. Using the video-recorded debriefings and INTERACT coding software, we applied timed, event-based coding with DE-CODE, a coding scheme for assessing debriefing interactions. We used lag sequential analysis to explore the relationship between what debriefers and participants said. We hypothesised that combining advocacy (ie, stating an observation followed by an opinion) with an open-ended question would be associated with participants' verbalisation of a mental model as a particular form of reflection.

RESULTS

The 50 debriefings with overall 114 participants had a mean duration of 49.35 min (SD=8.89 min) and included 18 486 behavioural transitions. We detected significant behavioural linkages from debriefers' observation to debriefers' opinion (z=9.85, p<0.001), from opinion to debriefers' open-ended question (z=9.52, p<0.001) and from open-ended question to participants' mental model (z=7.41, p<0.001), supporting our hypothesis. Furthermore, participants shared mental models after debriefers paraphrased their statements and asked specific questions but not after debriefers appreciated their actions without asking any follow-up questions. Participants also triggered reflection among themselves, particularly by sharing personal anecdotes.

CONCLUSION

When debriefers pair their observations and opinions with open-ended questions, paraphrase participants' statements and ask specific questions, they help participants reflect during debriefings.

Systematic Debriefing for Critical Events Facilitates Team Dynamics, Education, and Process Improvement

BACKGROUND

Debriefing is used in clinical settings to support interprofessional staff, improve processes, and identify educational needs. Nurses who lead debriefing sessions are empowered to improve processes.

PROBLEM

Nurse leaders identified the need for debriefing outside the critical care areas due to the rising acuity levels.

APPROACH

Two nurse leaders developed a debriefing initiative in one urban teaching hospital following rapid responses, codes, and stressful situations. Nurses developed a Debriefing Facilitation Guide to collect qualitative aspects of clinical emergencies to improve processes, education, and team dynamics.

OUTCOMES

Following each debriefing session, we deductively purposively coded the qualitative data into 3 a priori themes: the American Heart Association's team dynamics, process improvement, and educational opportunities. We identified opportunities for improvement for these themes during our first 54 debriefing sessions.

CONCLUSIONS

Following each debriefing session, the debriefing nurse leader intervened on all educational and process improvement opportunities identified and facilitated positive team dynamics.

From the Frontlines: A Qualitative Study of Staff Experiences With Clinical Event Debriefing

OBJECTIVES

Clinical event debriefing (CED) can improve patient care and outcomes, but little is known about CED across inpatient settings, and participant experiences have not been well described. In this qualitative study, we sought to characterize and compare staff experiences with CED in 2 hospital units, with a goal of generating recommendations for a hospital-wide debriefing program.

METHODS

We conducted 32 semistructured interviews with clinical staff who attended a CED in the previous week. We explored experiences with CED, with a focus on barriers and facilitators. We used content analysis with constant comparative coding to understand priorities identified by participants. We used inductive reasoning to develop a set of CED practice recommendations to match participant priorities.

RESULTS

Three primary themes emerged related to CED barriers and facilitators. (1) Factors affecting attendance: most respondents voiced a need for frontline staff inclusion in CED, but they also cited competing clinical duties and scheduling conflicts as barriers. (2) Factors affecting participant engagement: respondents described factors that influence participant engagement in reflective discussion. They described that the CED leader must cultivate a psychologically safe environment in which participants feel empowered to speak up, free from judgment. (3) Factors affecting learning and systems improvement: respondents emphasized that the CED group should generate a plan for improvement with accountable stakeholders. Collectively, these priorities propose several recommendations for CED practice, including frontline staff inclusion.

CONCLUSIONS

In this study, we propose recommendations for CED that are derived from first-hand participant experiences. Future study will explore implementation of CED practice recommendations.

"A debriefer must be neutral" and other debriefing myths: a systemic inquiry-based qualitative study of taken-for-granted beliefs about clinical post-event debriefing

BACKGROUND

The goal of this study was to identify taken-for-granted beliefs and assumptions about use, costs, and facilitation of post-event debriefing. These myths prevent the ubiquitous uptake of post-event debriefing in clinical units, and therefore the identification of process, teamwork, and latent safety threats that lead to medical error. By naming these false barriers and assumptions, the authors believe that clinical event debriefing can be implemented more broadly.

METHODS

We interviewed an international sample of 37 clinicians, educators, scholars, researchers, and healthcare administrators from hospitals, universities, and healthcare organizations in Western Europe and the USA, who had a broad range of debriefing experience. We adopted a systemic-constructivist approach that aimed at exploring in-depth assumptions about debriefing beyond obvious constraints such as time and logistics and focused on interpersonal relationships within organizations. Using circular questions, we intended to uncover new and tacit knowledge about barriers and facilitators of regular clinical debriefings. All interviews were transcribed and analyzed following a comprehensive process of inductive open coding.

RESULTS

In total, 1508.62 min of interviews (25 h, 9 min, and 2 s) were analyzed, and 1591 answers were categorized. Many implicit debriefing theories reflected current scientific evidence, particularly with respect to debriefing value and topics, the complexity and difficulty of facilitation, the importance of structuring the debriefing and engaging in reflective practice to advance debriefing skills. We also identified four debriefing myths which may prevent post-event debriefing from being implemented in clinical units.

CONCLUSION

The debriefing myths include (1) debriefing only when disaster strikes, (2) debriefing is a luxury, (3) senior clinicians should determine debriefing content, and (4) debriefers must be neutral and nonjudgmental. These myths offer valuable insights into why current debriefing practices are ad hoc and not embedded into daily unit practices. They may help ignite a renewed momentum into the implementation of post-event debriefing in clinical settings.

Applications of Postresuscitation Debriefing Frameworks in Emergency Settings: A Systematic Review

OBJECTIVES

Postresuscitation debriefing (PRD) is a valuable educational tool in emergency medicine. It is recommended by international resuscitation guidelines, has been shown to improve both patient outcomes and resuscitation team performance, and is frequently requested by medical learners. However, there is limited research comparing standardized debriefing frameworks. Not only does this hinder the ability of interested emergency departments (EDs) to adopt PRD, but it limits the quality of future debriefing research. We sought to identify and compare existing PRD frameworks to inform the implementation of effective PRD in emergency medicine.

METHODS

We conducted a systematic review following PRISMA standards to identify debriefing frameworks used in the ED and other acute care settings for further analysis. Identified frameworks were analyzed and compared based on a method previously described in the literature.

RESULTS

Our search identified six frameworks, which ranged from simple tools for immediate feedback to complex, hospital-wide systems engineering-based approaches to quality improvement. Key findings were the importance of ensuring debriefing facilitators are properly selected and trained and of tailoring framework design to specific organizational targets. However, there is limited validation data for these frameworks, and more study is needed to identify and validate true best practices in PRD.

CONCLUSIONS

All six identified frameworks seem to be effective methods of debriefing. Given the breadth in debriefing methods and goals identified, this suggests that there may not be a one-size-fits-all approach to PRD and that organizations should instead identify their own unique needs and barriers and adopt the debriefing framework that best addresses those needs. Other findings were the importance of well-trained debriefing facilitators and the use of clear roles in organizing debriefings. Further research is needed to assess the effectiveness of postresuscitation frameworks with regard to both team performance and patient outcomes.

Clinical event debriefing: a review of approaches and objectives

PURPOSE OF REVIEW

This review explores four different approaches and clarifies objectives for debriefing after a clinical event in the emergency department. Psychological debriefing aims to prevent or reduce symptoms of traumatic stress and normalize recovery. Psychological first aid helps team members provide each other with pragmatic social support. Debriefing for simulation-based education promotes learning by team members. Quality improvement approaches and after action reviews focus on systems improvement.

RECENT FINDINGS

Qualitative studies have begun to explore interactions between clinical staff after a significant clinical event. Clearer descriptions and measurements of quality improvements and the effect of clinical event debriefing on patient outcomes are appearing. An increasing number of studies describe melded, scripted approaches to the hot debrief.

SUMMARY

Clinical staff have consistently indicated they value debriefing after a significant clinical event. Differing objectives from different approaches have translated into a wide variety of methods and a lack of clarity about relevant outcomes to measure. Recent descriptions of scripted approaches may clarify these objectives and pave the way for measuring relevant outcomes that demonstrate the effectiveness of and find the place for debriefing in the emergency department.

Benefits of Using The Pause after Death in Emergency Departments: A Delphi Study

OBJECTIVE

The Pause is a short-term, microbreak created by an emergency nurse in 2009. It provides care team members a few seconds of silence to honor a patient who has died while also honoring the efforts of the team. It is used now on four continents as a standard of care. We investigated how it is being used and why.

METHODS

We used a modified Delphi methodology with purposive sampling and a descriptive approach. During the three-round Delphi, we created a data display using open, then axial coding to develop a thematic analysis. Member checking and reflexivity exercises were used to build reliability and trustworthiness of findings.

RESULTS

We analyzed 21 transcripts. The Pause is reported to be an ongoing practice in at least 23 health systems globally. Key themes such as Benefits, Self-Care, and Support of other Patients were most pertinent in our analysis.

CONCLUSION

The Pause is a low-risk, grassroots intervention that can be led by any member of a care team in emergency settings. It offers self-care for the individual and team. It helps emergency providers feel grounded after a death before going to treat another patient. According to our sample, The Pause helps reduce caregiver stress, which may decrease the risk for burnout. Although further research is recommended, we assert that The Pause be used as a standard of care in emergency departments across the United States.

“The Pause”: A Delphi Methodology Examining an End-of-Life Practice

“The Pause” was first practiced by a nurse at a Level 1 trauma center to honor the death of a deceased patient. This practice has spread internationally and is used in emergency departments, intensive care, transplant, and oncology units, in addition to pre-hospital settings. There is a paucity of research published on the effects of The Pause for health care workers. We used a three-staged Delphi methodology to understand the barriers, benefits, and language used in The Pause. Analyses of email communication and interview transcripts suggest that The Pause poses minimal risk and has considerable benefits. Benefits include increased perceived team cohesion, a moment for reflection, and a method by which to honor a deceased patient. The Pause allows nurses to feel more present to meet the needs of the next patient they care for during a shift. Further research is merited.