Debriefing as a Strategic Tool for Performance Improvement

[Development of a measuring tool for performance anxiety in obstetrics]

OBJECTIVE

Developing a measuring tool for physician's performance anxiety during obstetrical procedures, as a self-administered questionnaire.

METHODS

We used the Delphi method. First, we did a literature review to identify the items to submit for the first round. A panel of experts was asked to rate the relevance of items from one to six. For the first round of Delphi, items were retained if more than 70% of respondents assigned a five or six rating. Items were excluded if more than 70% of respondents assigned a one or two rating. All the other items, plus those suggested by the panel, were submitted to a second round of Delphi. The same item selection conditions were applied to the second round.

RESULTS

The overall response rate to the Delphi was 79% (19 respondents). At the end of the first round, 14 items were consensually relevant, no item was consensually irrelevant. For the second round, the 18 items that did not find consensus and seven new items suggested by the experts in the first round were submitted. At the end of the second round, nine items were retained by consensus as relevant.

CONCLUSION

This study defined by consensus 23 items for a self-questionnaire to measure specific performance anxiety in obstetrics divided into five dimensions: perceived stress, assessment of the risk of complications, medico-legal risk, impact of the healthcare team and peers, self-confidence and decision-making confidence. We intend to validate this tool in real population.

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.

Postpartum hemorrhage: The role of simulation

Postpartum hemorrhage (PPH) persists as a leading cause of maternal death worldwide, and in the United States, most maternal deaths due to hemorrhage are deemed preventable. While essential preparations for hemorrhage include protocols and checklists, implementation science has revealed that it is not enough to merely introduce these tools into units. Simulation affords safe opportunities for practice and produces reliable behavior change, and it does not always need to be highly expensive and resource consuming. We review how simulation can be applied to address a unit's vulnerabilities in identifying, managing, and resolving PPH, as well as considerations for crafting a comprehensive simulation program for your unit.

Improving Newborn Resuscitation by Making Every Birth a Learning Event

One third of all neonatal deaths are caused by intrapartum-related events, resulting in neonatal respiratory depression (i.e., failure to breathe at birth). Evidence-based resuscitation with stimulation, airway clearance, and positive pressure ventilation reduces mortality from respiratory depression. Improving adherence to evidence-based resuscitation is vital to preventing neonatal deaths caused by respiratory depression. Standard resuscitation training programs, combined with frequent simulation practice, have not reached their life-saving potential due to ongoing gaps in bedside performance. Complex neonatal resuscitations, such as those involving positive pressure ventilation, are relatively uncommon for any given resuscitation provider, making consistent clinical practice an unrealistic solution for improving performance. This review discusses strategies to allow every birth to act as a learning event within the context of both high- and low-resource settings. We review strategies that involve clinical-decision support during newborn resuscitation, including the visual display of a resuscitation algorithm, peer-to-peer support, expert coaching, and automated guidance. We also review strategies that involve post-event reflection after newborn resuscitation, including delivery room checklists, audits, and debriefing. Strategies that make every birth a learning event have the potential to close performance gaps in newborn resuscitation that remain after training and frequent simulation practice, and they should be prioritized for further development and evaluation.

Follow the protocol and kickstart the heart-Intensive care nurses' reflections on being part of rescue situations in interdisciplinary teams

Aim

To describe intensive care nurses' reflections on being part of interdisciplinary emergency teams involved in in‐hospital cardiopulmonary resuscitation.

Design

A qualitative descriptive design. Methods: Eighteen intensive care nurses from two regions and three hospitals in Sweden were interviewed. The data were analysed with General Inductive Analysis.

Results

The work for intensive care nurses in the emergency team was reflected in three phases: prevention, intervention and mitigation—referred as before, during and after the CPR situation.

Conclusions

The findings describe the complexity of being an intensive care nurse in an interdisciplinary emergency team, which entails managing advanced care with limited and unknown resources in a non‐familiar environment. The present findings have important clinical implications concerning the value of having debriefing sessions to reflect on and to talk about obstacles to and prerequisites for performing successful resuscitation.

Clinical debriefing: A concept analysis

AIMS AND OBJECTIVES

The purpose of this paper is to enhance nursing and collaborative practice by presenting a concept analysis of clinical debriefing and introducing an operational definition.

BACKGROUND

Debriefing has taken many forms, using a variety of approaches. Variations and inconsistencies in clinical debriefing, and its related terms, still exist in the clinical setting.

DESIGN

Concept analysis.

METHODS

Walker and Avant's eight-step approach to concept analysis.

RESULTS

The defining attributes of clinical debriefing identified in this analysis are described as the five E's: educated/experienced facilitator, environment, education, evaluation and emotions. Antecedents identified in this analysis include the critical event, the desire or need to review such an event and the organizational awareness to execute clinical debriefs. The consequences of clinical debriefings are primarily advantageous and positively impact involved nurses, healthcare teams, patients and organizations. Empirical referents of clinical debriefing are complex and multifactorial. The productivity of a clinical debrief can be enhanced through a series of proposed questions. Together, the defining attributes, antecedents and consequences shape a proposed operational definition of clinical debriefing.

CONCLUSION

Clinical debriefing is a valuable tool within healthcare organizations. Debriefing can be a holistic, interprofessional, collaborative experience when all five defining attributes are present. Further investigation is required to standardise debriefing practices in clinical settings.

RELEVANCE TO CLINICAL PRACTICE

A concept analysis on clinical debriefing promotes uniformity of debriefing practices, reflective practice among nurses and healthcare teams, and contributes to nursing science by creating a platform for the development of practice standards, research and theory development.

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.

Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Preeclampsia/Eclampsia

OBJECTIVE

To analyze quality improvement opportunities (QIOs) identified through review of cases of maternal death from preeclampsia/eclampsia by the California Pregnancy-Associated Mortality Review Committee.

DESIGN

Qualitative descriptive design using thematic analysis.

SAMPLE

A total of 242 QIOs identified from 54 cases of pregnancy-related deaths from preeclampsia/eclampsia in California between 2002 and 2007.

METHODS

We coded and thematically organized the 242 QIOs using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis.

RESULTS

Standardized Policies and Protocols to manage severe hypertension and respond to obstetric emergencies was the main theme identified in the Readiness domain. For Recognition, issues related to Missed Clinical Warning Signs of worsening preeclampsia/eclampsia were predominant. In the Response domain, the themes Inadequate Assessment and Treatment of severe hypertension and Coordination of Care were most frequently noted.

CONCLUSION

Findings from our study suggest numerous opportunities to improve care and outcomes for women who died of preeclampsia/eclampsia in California from 2002 to 2007. Facilities need to adopt and implement standardized policies and protocols about the diagnosis and treatment of preeclampsia/eclampsia. Clinician education about key warning signs is critical, as is ensuring that women understand the signs and symptoms that warrant immediate clinical attention. Death from preeclampsia/eclampsia is very preventable, and efforts to reduce maternal mortality and morbidity from this serious condition of pregnancy are needed at all levels.

Clinical Presentation and Treatment of Amniotic Fluid Embolism

Obstetric emergencies often require intensive care intervention. Amniotic fluid embolism is a rare, unpredictable, and often catastrophic complication of pregnancy that is suspected in a woman who experiences cardiac arrest after a cesarean section. The condition occurs in approximately 1 in 40 000 births and has an average case-fatality rate of 16%. This complication may result from activation of an inflammatory response to fetal tissue in the maternal circulation. Risk factors may include maternal age over 35 years and conditions in which fluid can exchange between the maternal and fetal circulations. The presentation is abrupt, with profound cardiovascular and respiratory compromise, encephalopathy, fetal distress, and disseminated intravascular coagulopathy. Diagnosis is by exclusion and clinical presentation. Treatment is supportive, with a focus on reversal of hypoxia and hypotension, delivery of the fetus, and correction of coagulopathy. Staff debriefing and psychological support for the woman and family are vital.

National Partnership for Maternal Safety Consensus Bundle on Obstetric Hemorrhage

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. The safety bundle is organized into 4 domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and "Potential Best Practices" to assist with implementation.

Splenic artery aneurysm rupture during pregnancy

Abdominal pain is commonly reported by women seeking care in obstetric triage, and although it it is often benign, careful assessment is warranted. A rare cause of left upper quadrant pain during pregnancy is splenic artery aneurysm rupture, which can result in massive hemorrhage and maternal and fetal mortality. In women who survive, serious complications from bleeding and multiple transfusions require intensive care. There have been reports in the literature of improved outcomes with utilization of hemostatic resuscitation protocols. Nurses and other healthcare providers must be prepared to support families in the aftermath of this critical event. This article includes a case example of splenic artery aneurysm rupture that resulted in perinatal loss.

Introduction to debriefing

Debriefing is a lynchpin in the process of learning. As a post-experience analytic process, debriefing is a discussion and analysis of an experience, evaluating and integrating lessons learned into one's cognition and consciousness. Debriefing provides opportunities for exploring and making sense of what happened during an event or experience, discussing what went well and identifying what could be done to change, improve and do better next time. This manuscript serves as an introduction to debriefing, covering a range of topics that include a brief review of its origin, the structure and process of debriefing-specifically in the context of simulation-based medical education, and factors that facilitate effective, successful debriefing. An approach to debriefing immediately after real clinical events will be presented, as well as an evidence-based approach to evaluating debriefing skills of healthcare simulation instructors.

Surgical debriefing: a reliable roadmap to completing the patient safety cycle

Morbidity and mortality due to preventable medical errors are a disastrous reality in medicine. Debriefing, a process that allows individuals to discuss team performance in a constructive, supportive environment, has been linked to improved performance in various medical and surgical fields, including improvements in specific procedures, teamwork and communication, and error identification. However, the neurosurgical literature on this topic is limited. The authors review the debriefing literature in the field of medicine, with a specific emphasis on the operating room, and they report their own institutional experience with a debriefing module, from invention to pilot implementation, at Vanderbilt University Medical Center. The authors share the challenges and lessons learned from their quality improvement project. The field of neurosurgery would undoubtedly benefit from embracing debriefing, as its potential has been established in other medical specialties and can serve as a valuable role in immediately learning from mistakes. The authors hope that their colleagues can learn from this experience and improve their own.