An Evaluation of a New Debriefing Framework: REFLECT

A success story of clinical debriefings: lessons learned to promote impact and sustainability

The COVID-19 crisis impacted emergency departments (ED) unexpectedly and exposed teams to major issues within a constantly changing environment. We implemented post-shift clinical debriefings (CDs) from the beginning of the crisis to cope with adaptability needs. As the crisis diminished, clinicians voiced a desire to maintain the post-shift CD program, but it had to be reshaped to succeed over the long term. A strategic committee, which included physician and nurse leadership and engaged front-line staff, designed and oversaw the implementation of CD. The CD structure was brief and followed a debriefing with a good judgment format. The aim of our program was to discover and integrate an organizational learning strategy to promote patient safety, clinicians' wellbeing, and engagement with the post-shift CD as the centerpiece. In this article, we describe how post-shift CD process was performed, lessons learned from its integration into our ED strategy to ensure value and sustainability and suggestions for adapting this process at other institutions. This novel application of debriefing was well received by staff and resulted in discovering multiple areas for improvement ranging from staff interpersonal interactions and team building to hospital wider quality improvement initiatives such as patient throughput.

Data-informed debriefing for cardiopulmonary arrest: A randomized controlled trial

Aim

To determine if data-informed debriefing, compared to a traditional debriefing, improves the process of care provided by healthcare teams during a simulated pediatric cardiac arrest.

Methods

We conducted a prospective, randomized trial. Participants were randomized to a traditional debriefing or a data-informed debriefing supported by a debriefing tool. Participant teams managed a 10-minute cardiac arrest simulation case, followed by a debriefing (i.e. traditional or data-informed), and then a second cardiac arrest case. The primary outcome was the percentage of overall excellent CPR. The secondary outcomes were compliance with AHA guidelines for depth and rate, chest compression (CC) fraction, peri-shock pause duration, and time to critical interventions.

Results

A total of 21 teams (84 participants) were enrolled, with data from 20 teams (80 participants) analyzed. The data-informed debriefing group was significantly better in percentage of overall excellent CPR (control vs intervention: 53.8% vs 78.7%; MD 24.9%, 95%CI: 5.4 to 44.4%, p = 0.02), guideline-compliant depth (control vs. intervention: 60.4% vs 85.8%, MD 25.4%, 95%CI: 5.5 to 45.3%, p = 0.02), CC fraction (control vs intervention: 88.6% vs 92.6, MD 4.0%, 95%CI: 0.5 to 7.4%, p = 0.03), and peri-shock pause duration (control vs intervention: 5.8 s vs 3.7 s, MD -2.1 s, 95%CI: -3.5 to -0.8 s, p = 0.004) compared to the control group. There was no significant difference in time to critical interventions between groups.

Conclusion

When compared with traditional debriefing, data-informed debriefing improves CPR quality and reduces pauses in CPR during simulated cardiac arrest, with no improvement in time to critical interventions.

A systematic scoping review on the evidence behind debriefing practices for the wellbeing/emotional outcomes of healthcare workers

Introduction

Debriefings give healthcare workers voice through the opportunity to discuss unanticipated or difficult events and recommend changes. The typical goal of routine debriefings has been to improve clinical outcomes by learning through discussion and reflection of events and then transferring that learning into clinical practice. However, little research has investigated the effects of debriefings on the emotional experiences and well-being of healthcare workers. There is some evidence that debriefings are a multi-faceted and cost-effective intervention for minimising negative health outcomes, but their use is inconsistent and they are infrequently adopted with the specific intention of giving healthcare workers a voice. The purpose of this systematic scoping review is therefore to assess the scope of existing evidence on debriefing practices for the well-being and emotional outcomes of healthcare workers.

Methods

Following screening, 184 papers were synthesised through keyword mapping and exploratory trend identification.

Results

The body of evidence reviewed were clustered geographically, but diverse on many other criteria of interest including the types of evidence produced, debriefing models and practices, and outcomes captured.

Discussion

The current review provides a clear map of our existing understanding and highlights the need for more systematic, collaborative and rigorous bodies of evidence to determine the potential of debriefing to support the emotional outcomes of those working within healthcare.

Systematic Review Registration

https://osf.io/za6rj.

Embracing informed learner self-assessment during debriefing: the art of plus-delta

The healthcare simulation field has no shortage of debriefing options. Some demand considerable skill which serves as a barrier to more widespread implementation. The plus-delta approach to debriefing offers the advantages of conceptual simplicity and ease of implementation. Importantly, plus-delta promotes learners' capacity for a self-assessment, a skill vital for safe clinical practice and yet a notorious deficiency in professional practice. The plus-delta approach confers the benefits of promoting uptake of debriefing in time-limited settings by educators with both fundamental but also advanced skills, and enhancing essential capacity for critical self-assessment informed by objective performance feedback. In this paper, we describe the role of plus-delta in debriefing, provide guidance for incorporating informed learner self-assessment into debriefings, and highlight four opportunities for improving the art of the plus delta: (a) exploring the big picture vs. specific performance issues, (b) choosing between single vs. double-barreled questions, (c) unpacking positive performance, and (d) managing perception mismatches.

"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.

[Debriefing in pediatric emergency care]

Kommunikationsfehler und systembedingte Probleme wirken sich negativ auf Teamarbeit und gemeinsame Entscheidungsfindung aus und können den Patienten Schaden zufügen. Regelmäßige Nachbesprechungen nach kritischen Ereignissen wiederum wirken sich positiv auf die Teamzusammenarbeit und das Patientenoutcome in der Kindernotfallversorgung aus. Das gemeinsame Reflektieren fördert das Lernen, hilft den Teams, sich zu verbessern, und verhindert, dass sich Fehler in Zukunft wiederholen. Dennoch werden Debriefings im präklinischen und klinischen Alltag noch immer qualitativ unzureichend durchgeführt. Gründe dafür sind mangelnde Zeit, Fehlen von erfahrenen Debriefern und fehlende Unterstützung durch Verantwortungsträger. Debriefings können je nach Bedarf zu verschiedenen Zeitpunkten mit unterschiedlicher Dauer stattfinden. Nachbesprechungen können auch rein virtuell oder als sogenannte Hybridveranstaltung durchgeführt werden. Nachbesprechungen sollten sich auf gemeinsames Lernen und das Erarbeiten zukunftsorientierter Verbesserungen konzentrieren. Nicht nur lebensbedrohliche Ereignisse können Nachbesprechungen auslösen, sondern auch potenziell kritische Situationen, wie routinemäßige Intubationen. Debriefing-Skripte fördern eine Strukturierung und ermöglichen selbst unerfahrenen Moderatoren, alle Aspekte zu bearbeiten. Neben der Diskussion schwieriger Abläufe sollten unbedingt positive Leistungen besprochen werden, um diese zu verstärken und das Lernen am Erfolg zu ermöglichen. Dabei sollten die Beweggründe eines Verhaltens erfragt und nicht nur die nach außen sichtbaren Leistungen bewertet werden. Diese Strategie fördert bedarfsgerechtes Lernen und konzentriert sich auf Lösungen. Hilfreich sind dabei spezielle Fragetechniken, echtes Interesse und eine positive Sicherheitskultur.

Development and implementation of an end-of-shift clinical debriefing method for emergency departments during COVID-19

BACKGROUND

Multiple guidelines recommend debriefing after clinical events in the emergency department (ED) to improve performance, but their implementation has been limited. We aimed to start a clinical debriefing program to identify opportunities to address teamwork and patient safety during the COVID-19 pandemic.

METHODS

We reviewed existing literature on best-practice guidelines to answer key clinical debriefing program design questions. An end-of-shift huddle format for the debriefs allowed multiple cases of suspected or confirmed COVID-19 illness to be discussed in the same session, promoting situational awareness and team learning. A novel ED-based clinical debriefing tool was implemented and titled Debriefing In Situ COVID-19 to Encourage Reflection and Plus-Delta in Healthcare After Shifts End (DISCOVER-PHASE). A facilitator experienced in simulation debriefings would facilitate a short (10-25 min) discussion of the relevant cases by following a scripted series of stages for debriefing. Data on the number of debriefing opportunities, frequency of utilization of debriefing, debriefing location, and professional background of the facilitator were analyzed.

RESULTS

During the study period, the ED treated 3386 suspected or confirmed COVID-19 cases, with 11 deaths and 77 ICU admissions. Of the 187 debriefing opportunities in the first 8-week period, 163 (87.2%) were performed. Of the 24 debriefings not performed, 21 (87.5%) of these were during the four first weeks (21/24; 87.5%). Clinical debriefings had a median duration of 10 min (IQR 7-13). They were mostly facilitated by a nurse (85.9%) and mainly performed remotely (89.8%).

CONCLUSION

Debriefing with DISCOVER-PHASE during the COVID-19 pandemic were performed often, were relatively brief, and were most often led remotely by a nurse facilitator. Future research should describe the clinical and organizational impact of this DISCOVER-PHASE.

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.

“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.

Frameworks and quality measures used for debriefing in team-based simulation: a systematic review

Objectives

The skill of the debriefer is known to be the strongest independent predictor of the quality of simulation encounters yet educators feel underprepared for this role. The aim of this review was to identify frameworks used for debriefing team-based simulations and measures used to assess debriefing quality.

Methods

We systematically searched PubMed, CINAHL, MedLine and Embase databases for simulation studies that evaluated a debriefing framework. Two reviewers evaluated study quality and retrieved information regarding study methods, debriefing framework, outcome measures and debriefing quality.

Results

A total of 676 papers published between January 2003 and December 2017 were identified using the search protocol. Following screening of abstracts, 37 full-text articles were assessed for eligibility, 26 studies met inclusion criteria for quality appraisal and 18 achieved a sufficiently high-quality score for inclusion in the evidence synthesis. A debriefing framework was used in all studies, mostly tailored to the study. Impact of the debrief was measured using satisfaction surveys (n=11) and/or participant performance (n=18). Three themes emerged from the data synthesis: selection and training of facilitators, debrief model and debrief assessment. There was little commonality across studies in terms of participants, experience of faculty and measures used.

Conclusions

A range of debriefing frameworks were used in these studies. Some key aspects of debrief for team-based simulation, such as facilitator training, the inclusion of a reaction phase and the impact of learner characteristics on debrief outcomes, have no or limited evidence and provide opportunities for future research particularly with interprofessional groups.