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Rousseau AF, Fontana M, Georis S, Lambermont B, Cavalleri J, Pirotte M, Tronconi G, Paquay M, Misset B. Implementation of a routine post-shift debriefing program in ICU aiming at quality-of-care improvement: A primary analysis of feasibility and impacts. Intensive Crit Care Nurs 2024; 84:103752. [PMID: 38896963 DOI: 10.1016/j.iccn.2024.103752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 05/02/2024] [Accepted: 06/10/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVES This report describes the implementation of a clinical debriefing (CD) program in intensive care units (ICU) and analyses its feasibility and its impact on staff well-being. DESIGN Observational study. SETTING From April to September 2023, post-shift CDs were run once a week in 2 out of 7 units in our department, using an adapted version of the DISCOVER-PHASE tool. CD sessions were performed face-to-face with volunteer members of the multidisciplinary ICU team. MAIN OUTCOME MEASURES After 6 months, a survey assessing the satisfaction of the debriefed teams was conducted. The impact of CD on staff well-being was assessed using three validated questionnaires (Maslach Burnout Inventory, Ways of Coping Checklist, Professional Quality of Life Scale) administered in the 7 units before and after the CD period. RESULTS A total of 44 CDs were performed, lasting 15 (4-35) min. There were 6 (1-9) attendees per CD, mainly nurses (64.6%). Discussions focused mainly on basic problems related to dysfunctional material, communication and organization inside the team. The two debriefed teams were satisfied of the program and gave 9, 8 and 8 out of 10 on a visual analogical scale for the climate of confidence of the DC, their organisation, and their ability to improve working conditions and quality of care, respectively. Subscores at the three questionnaires assessing staff well-being before and after the CD period were similar, whether teams experienced CD or not. CONCLUSIONS Implementing of post-shift debriefings in our ICU was feasible and well accepted. More prolonged programs are probably needed to demonstrate benefits on staff well-being. IMPLICATIONS FOR CLINICAL PRACTICE This report offers elements that other teams can use to successfully conduct post-shift debriefings and to plan future research on longer-term programs.
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Affiliation(s)
- Anne-Françoise Rousseau
- Intensive Care Department, University Hospital of Liège, University of Liège, Belgium; Research Unit for a Life-Course Perspective on Health & Education-RUCHE, University of Liège, Liège, Belgium.
| | - Michael Fontana
- Intensive Care Department, University Hospital of Liège, University of Liège, Belgium
| | - Stéphanie Georis
- Intensive Care Department, University Hospital of Liège, University of Liège, Belgium
| | - Bernard Lambermont
- Intensive Care Department, University Hospital of Liège, University of Liège, Belgium
| | - Jonathan Cavalleri
- Intensive Care Department, University Hospital of Liège, University of Liège, Belgium
| | - Marc Pirotte
- Intensive Care Department, University Hospital of Liège, University of Liège, Belgium
| | - Gaëlle Tronconi
- Intensive Care Department, University Hospital of Liège, University of Liège, Belgium
| | - Méryl Paquay
- Centre for Medical Simulation, University of Liège, Belgium; Emergency Department, University Hospital of Liège, University of Liège, Belgium
| | - Benoit Misset
- Intensive Care Department, University Hospital of Liège, University of Liège, Belgium
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Bohorquez J, Patel AD, Borders R, Gorman A, Reynolds C, Ritchie K, Denson N, Solomon CM. Routine Postclinical Event Debriefings on Inpatient Pediatric Units. Hosp Pediatr 2024; 14:632-641. [PMID: 38982950 PMCID: PMC11287061 DOI: 10.1542/hpeds.2023-007452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 03/22/2024] [Accepted: 04/06/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND AND OBJECTIVES Debriefings are an underutilized opportunity to enhance team performance and safety culture. Little is known about the impact of postclinical event debriefing programs in Pediatric Hospital Medicine (PHM). We sought to develop a standardized debriefing process with multidisciplinary involvement after all clinical events on PHM service lines. Our primary aim was to achieve 75% debriefing completion rate over 12 months with debriefing duration less than 10 minutes. METHODS A standardized postclinical event debriefing process was created at a large tertiary children's hospital. We aimed to debrief after clinical events on PHM services. The debriefing process was developed with key stakeholders and used a key driver diagram and Plan-Do-Study-Act cycles to refine the process. The project team reviewed the data monthly. RESULTS During our 20-month study period, debriefing completion rate sustained a median of 66% with a median debriefing time of 7 minutes. Most debriefings (61%) had all core team members present with attending physicians (pediatric hospitalists) being absent most often. Barriers to debriefing with all core members present included service type, time of day, and shift change. Process changes were implemented based on concerns addressed in the debriefings. CONCLUSIONS Multidisciplinary, postclinical event debriefings were successfully implemented on inpatient pediatric wards. Future steps include process implementation on non-PHM units in our hospital based on expressed interest and to further assess how debriefings optimize team performance and improve clinical outcomes.
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Affiliation(s)
- Jenny Bohorquez
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Amee D. Patel
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - April Gorman
- Peter O’Donnell Jr School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Kristin Ritchie
- Peter O’Donnell Jr School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Natalie Denson
- Peter O’Donnell Jr School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Courtney M. Solomon
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
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Paxino J, Szabo RA, Marshall S, Story D, Molloy E. What and when to debrief: a scoping review examining interprofessional clinical debriefing. BMJ Qual Saf 2024; 33:314-327. [PMID: 38160060 DOI: 10.1136/bmjqs-2023-016730] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/08/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Clinical debriefing (CD) improves teamwork and patient care. It is implemented across a range of clinical contexts, but delivery and structure are variable. Furthermore, terminology to describe CD is also inconsistent and often ambiguous. This variability and the lack of clear terminology obstructs understanding and normalisation in practice. This review seeks to examine the contextual factors relating to different CD approaches with the aim to differentiate them to align with the needs of different clinical contexts. METHODS Articles describing CD were extracted from Medline, CINAHL, ERIC, PubMed, PsychINFO and Academic Search Complete. Empirical studies describing CD that involved two or more professions were eligible for inclusion. Included papers were charted and analysed using the Who-What-When-Where-Why-How model to examine contextual factors which were then used to develop categories of CD. Factors relating to what prompted debriefing and when debriefing occurred were used to differentiate CD approaches. RESULTS Forty-six papers were identified. CD was identified as either prompted or routine, and within these overarching categories debriefing was further differentiated by the timing of the debrief. Prompted CD was either immediate or delayed and routine CD was postoperative or end of shift. Some contextual factors were unique to each category while others were relatively heterogeneous. These categories help clarify the alignment between the context and the intention of CD. CONCLUSIONS The proposed categories offer a practical way to examine and discuss CD which may inform decisions about implementation. By differentiating CD according to relevant contextual factors, these categories may reduce confusion which currently hinders discourse and implementation. The findings from this review promote context-specific language and a shift away from conceptions of CD that embody a one-size-fits-all approach.
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Affiliation(s)
- Julia Paxino
- Department of Medical Education, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rebecca A Szabo
- Department of Medical Education, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Stuart Marshall
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - David Story
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth Molloy
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
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Sather NK, Zinns LE, Brennan G, Guo L, Khan N, Havalad V. Survey of Pediatric Critical Care Fellows on Postresuscitation Debriefing. J Patient Cent Res Rev 2023; 10:247-254. [PMID: 38046994 PMCID: PMC10688913 DOI: 10.17294/2330-0698.2036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
Purpose Current guidelines recommend debriefing following medical resuscitations to improve patient outcomes. The goal of this study was to describe national trends in postresuscitation debriefing practices among pediatric critical care medicine (PCCM) fellows to identify potential gaps in fellow education. Methods A 13-item survey was distributed to fellows in all 76 ACGME-accredited PCCM programs in the United States in the spring of 2021. The online survey addressed frequency and timing of debriefings following medical resuscitations, whether formal training is provided, which medical professionals are present, and providers' comfort level leading a debriefing. Results were analyzed using descriptive statistics. Results A total of 102 responses (out of a possible N of 536) were gathered from current PCCM fellows. All fellows (100%) reported participation in a medical resuscitation. Only 21% stated that debriefings occurred after every resuscitation event, and 44% did not follow a structured protocol for debriefing. While 66% reported feeling very or somewhat comfortable leading the debriefing, 19% felt either somewhat uncomfortable or very uncomfortable. A vast majority (92%) of participating fellows believed that debriefing would be helpful in improving team member performance during future resuscitations, and 92% expressed interest in learning more about debriefing. Conclusions The majority of PCCM fellows do not receive formal training on how to lead a debriefing. Given that 74% of fellows in our study did not feel very comfortable leading a debriefing but almost universally expressed that this practice is useful for provider well-being and performance, there is a clear need for increased incorporation of debriefing training into PCCM curricula across the United States.
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Affiliation(s)
| | - Lauren E. Zinns
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gillian Brennan
- Neonatology, Department of Pediatrics, University of Chicago Comer Children’s Hospital, Chicago, IL
| | - Lily Guo
- Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Nadia Khan
- Pediatric Critical Care, Advocate Children’s Hospital, Park Ridge, IL
| | - Vinod Havalad
- Pediatric Critical Care, Advocate Children’s Hospital, Park Ridge, IL
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Mullan PC, Jennings AD, Stricklan E, Martinez E, Weeks M, Mitchell K, Vazifedan T, Andam-Mejia R, Spencer DB. Reducing physical restraints in pediatrics: A quality improvement mixed-methods analysis of implementing a clinical debriefing process after behavioural health emergencies in a Children's Hospital. Curr Probl Pediatr Adolesc Health Care 2023; 53:101463. [PMID: 38000959 DOI: 10.1016/j.cppeds.2023.101463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
INTRODUCTION An increasing number of pediatric patients with mental and behavioral health (MBH) conditions present to Emergency Department (ED) and inpatient settings with behavioral events that require physical restraint (PR). PR usage is associated with adverse outcomes. Clinical debriefing (CD) programs have been associated with improved performance but have not been studied in this population. After implementing an MBH-CD program in our Children's Hospital, we aimed to decrease the baseline (7/2018-3/2021) rate of a second PR episode (2PR) by 50 % in the ED and inpatient settings over two years. METHODS A multidisciplinary team implemented an MBH-CD process in April 2021 for hospital teams to use immediately after behavioral events. We included patients ≤18 years old, with an ED or inpatient discharge MBH diagnosis, between July 2018 and June 2023. Pre- and post-implementation secondary outcomes included the ED median duration of PR and the ED PR time per 1000 h of ED care. ED and inpatient mean length of stay (LOS) and mean monthly visits (MMV) in pre- and post-implementation were also compared. Qualitative analysis identified major themes. RESULTS Post-implementation, the ED significantly decreased 2PR rate by 67 %; in inpatients, no significant change was demonstrated. Median duration of ED PR decreased from 112 to 71 min (p = 0.006) and ED PR time significantly decreased by 82 % (14.8 to 2.7 h per 1000 h). In the post-implementation period, mean LOS (ED and inpatient) and MMV (ED only) were significantly higher. Fifty-one percent of 494 behavioral alerts were debriefed. Median debriefing duration was 6 min (IQR 4,10). Common themes included cooperation and coordination (23 %) and clinical standards (14 %). DISCUSSION Clinical debriefing implementation was associated with significant improvement in ED patient outcomes. Inpatient outcomes were unchanged, but debriefings in both settings should enable frontline teams to continuously identify opportunities to improve future outcomes.
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Affiliation(s)
- Paul C Mullan
- Children's Hospital of the King's Daughters, Norfolk, VA, United States; Eastern Virginia Medical School, Norfolk, VA, United States.
| | - Andrea D Jennings
- Children's Hospital of the King's Daughters, Norfolk, VA, United States
| | - Erin Stricklan
- Children's Hospital of the King's Daughters, Norfolk, VA, United States
| | | | - Monica Weeks
- Children's Hospital of the King's Daughters, Norfolk, VA, United States
| | - Karen Mitchell
- Children's Hospital of the King's Daughters, Norfolk, VA, United States
| | - Turaj Vazifedan
- Children's Hospital of the King's Daughters, Norfolk, VA, United States
| | | | - Daniel B Spencer
- Children's Hospital of the King's Daughters, Norfolk, VA, United States; Eastern Virginia Medical School, Norfolk, VA, United States
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Paquay M, Simon R, Ancion A, Graas G, Ghuysen A. A success story of clinical debriefings: lessons learned to promote impact and sustainability. Front Public Health 2023; 11:1188594. [PMID: 37475771 PMCID: PMC10354544 DOI: 10.3389/fpubh.2023.1188594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/14/2023] [Indexed: 07/22/2023] Open
Abstract
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.
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Affiliation(s)
- Méryl Paquay
- Emergency Department, University Hospital of Liege Quartier Hôpital, Liege, Belgium
- Center for Medical Simulation of Liege, Quartier Hôpital, University of Liege, Liege, Belgium
| | | | - Aurore Ancion
- Emergency Department, University Hospital of Liege Quartier Hôpital, Liege, Belgium
| | - Gwennaëlle Graas
- Center for Medical Simulation of Liege, Quartier Hôpital, University of Liege, Liege, Belgium
| | - Alexandre Ghuysen
- Emergency Department, University Hospital of Liege Quartier Hôpital, Liege, Belgium
- Center for Medical Simulation of Liege, Quartier Hôpital, University of Liege, Liege, Belgium
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Paquay M, Diep AN, Kabanda Z, Ancion A, Piazza J, Ghuysen A. Impact of the Covid-19 crisis on the hospital work environment and organization: A mixed-methods study. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2023. [DOI: 10.1080/20479700.2023.2190252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Affiliation(s)
- Méryl Paquay
- Emergency Department, University Hospital of Liege, Quartier Hôpital, Liege, Belgium
- Center for Medical Simulation of Liege, Quartier Hôpital, University of Liege, Liege, Belgium
| | - Anh Nguyet Diep
- Biostatistics Unit, Quartier Hôpital, University of Liège, Liège, Belgium
| | - Zoé Kabanda
- Center for Medical Simulation of Liege, Quartier Hôpital, University of Liege, Liege, Belgium
| | - Aurore Ancion
- Emergency Department, University Hospital of Liege, Quartier Hôpital, Liege, Belgium
| | - Justine Piazza
- Emergency Department, University Hospital of Liege, Quartier Hôpital, Liege, Belgium
| | - Alexandre Ghuysen
- Emergency Department, University Hospital of Liege, Quartier Hôpital, Liege, Belgium
- Center for Medical Simulation of Liege, Quartier Hôpital, University of Liege, Liege, Belgium
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Kolbe M, Grande B, Lehmann-Willenbrock N, Seelandt JC. Helping healthcare teams to debrief effectively: associations of debriefers' actions and participants' reflections during team debriefings. BMJ Qual Saf 2023; 32:160-172. [PMID: 35902231 DOI: 10.1136/bmjqs-2021-014393] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 06/21/2022] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Michaela Kolbe
- Simulation Centre, University Hospital Zurich, Zurich, Switzerland .,ETH Zürich, Zurich, Switzerland
| | - Bastian Grande
- Simulation Centre, University Hospital Zurich, Zurich, Switzerland.,Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
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Association of burnout and intention-to-leave the profession with work environment: A nationwide cross-sectional study among Belgian intensive care nurses after two years of pandemic. Int J Nurs Stud 2023; 137:104385. [PMID: 36423423 PMCID: PMC9640385 DOI: 10.1016/j.ijnurstu.2022.104385] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/27/2022] [Accepted: 10/30/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Intensive care unit (ICU) nurses are at an increased risk of burnout and may have an intention-to-leave their jobs. The COVID-19 pandemic may increase this risk. OBJECTIVE The objective of this study was to describe the prevalence of burnout risk and intention-to-leave the job and nursing profession among ICU nurses and to analyse the relationships between these variables and the work environment after two years of the COVID-19 pandemic. DESIGN A national cross-sectional survey of all nurses working in Belgian ICUs was conducted between December 2021 and January 2022 during the 4th and 5th waves of the COVID-19 pandemic in Belgium. The Practice Environment Scale of the Nursing Work Index (PES-NWI) was used to measure the work environment, intention-to-leave the hospital and/or the profession was assessed. The risk of burnout was assessed using the Maslach Burnout Inventory scale including emotional exhaustion, depersonalisation, and reduced personal accomplishment. SETTING Nurses in 78 out of 123 Belgian hospital sites with an ICU participated in the survey. PARTICIPANTS 2321 out of 4851 nurses (47.8%) completed the entire online survey. RESULTS The median overall risk of burnout per hospital site (high risk in all three subdimensions) was 17.6% [P25: 10.0 - P75: 28.8] and the median proportion of nurses with a high risk in at least one subdimension of burnout in Belgian ICUs was 71.6% [56.7-82.7]. A median of 42.9% [32.1-57.1] of ICU nurses stated that they intended-to-leave the job and 23.8% [15.4-36.8] stated an intent-to-leave the profession. The median overall score of agreement with the presence of positive aspects in the work environment was 49.0% [44.8-55.8]. Overall, nurses working in the top 25% of best-performing hospital sites with regard to work environment had a statistically significant lower risk of burnout and intention-to-leave the job and profession compared to those in the lowest performing 25% of hospital sites. Patient-to-nurse ratio in the worst performing quartile was associated with a higher risk for emotional exhaustion (OR = 1.53, 95% CI:1.04-2.26) and depersonalisation (OR = 1.48, 95% CI:1.03-2.13) and intention-to-leave the job (OR = 1.46, 95% CI:1.03-2.05). CONCLUSIONS In this study, a high prevalence of burnout risk and intention-to-leave the job and nursing profession was observed after two years of the COVID-19 pandemic. Nevertheless, there was substantial variation across hospital sites which was associated with the quality of the work environment. TWEETABLE ABSTRACT "Burnout & intention to leave was high for Belgian ICU nurses after 2 years of COVID, but wellbeing was better with high quality work environments and more favourable patient to nurse ratios".
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Team debriefing in the COVID-19 pandemic: a qualitative study of a hospital-wide clinical event debriefing program and a novel qualitative model to analyze debriefing content. Adv Simul (Lond) 2022; 7:36. [PMID: 36303254 PMCID: PMC9612619 DOI: 10.1186/s41077-022-00226-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 09/09/2022] [Indexed: 11/23/2022] Open
Abstract
Background Healthcare workers faced unique challenges during the early months of the COVID-19 pandemic which necessitated rapid adaptation. Clinical event debriefings (CEDs) are one tool that teams can use to reflect after events and identify opportunities for improving their performance and their processes. There are few reports of how teams have used CEDs in the COVID-19 pandemic. Our aim is to explore the issues discussed during COVID-19 CEDs and propose a framework model for qualitatively analyzing CEDs. Methods This was a descriptive, qualitative study of a hospital-wide CED program at a quaternary children’s hospital between March and July 2020. CEDs were in-person, team-led, voluntary, scripted sessions using the Debriefing in Suspected COVID-19 to Encourage Reflection and Team Learning (DISCOVER-TooL). Debriefing content was qualitatively analyzed using constant comparative coding with an integrated deductive and inductive approach. A novel conceptual framework was proposed for understanding how debriefing content can be employed at various levels in a health system for learning and improvement. Results Thirty-one debriefings were performed and analyzed. Debriefings had a median of 7 debriefing participants, lasted a median of 10 min, and were associated with multiple systems-based process improvements. Fourteen themes and 25 subthemes were identified and categorized into a novel Input-Mediator-Output-Input Debriefing (IMOID) model. The most common themes included communication, coordination, situational awareness, team member roles, and clinical standards. Conclusions Teams identified diverse issues in their debriefing discussions related to areas of high performance and opportunities for improvement in their care of COVID-19 patients. This model may help healthcare systems to understand how CED tools can be used to accelerate organizational learning to promote safety and improve outcomes in changing clinical environments. Supplementary Information The online version contains supplementary material available at 10.1186/s41077-022-00226-z.
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Paquay M, Dubois N, Diep AN, Graas G, Sassel T, Piazza J, Servotte JC, Ghuysen A. “Debriefing and Organizational Lessons Learned” (DOLL): A Qualitative Study to Develop a Classification Framework for Reporting Clinical Debriefing Results. Front Med (Lausanne) 2022; 9:882326. [PMID: 35814768 PMCID: PMC9263566 DOI: 10.3389/fmed.2022.882326] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/26/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe COVID-19 crisis has radically affected our healthcare institutions. Debriefings in clinical settings provide a time for the clinicians to reflect on the successes (pluses) and difficulties (deltas) encountered. Debriefings tend to be well-received if included in the broader management of the unit. The goal of this study was to develop a framework to categorize these debriefings and to assess its worthiness.MethodsA qualitative approach based on a grounded theory research method was adopted resulting in the “Debriefing and Organizational Lessons Learned” (DOLL) framework. Debriefings were conducted within two Emergency Departments of a Belgian University Hospital during an 8-week period. In the first step, three researchers used debriefing transcripts to inductively develop a tentative framework. During the second step, these three researchers conducted independent categorizations of the debriefings using the developed framework. In step 3, the team analyzed the data to understand the utility of the framework. Chi-square was conducted to examine the associations between the item types (pluses and deltas) and the framework's dimensions.ResultsThe DOLL is composed of seven dimensions and 13 subdimensions. Applied to 163 debriefings, the model identified 339 items, including 97 pluses and 242 deltas. Results revealed that there was an association between the frequency of pluses and deltas and the dimensions (p < 0.001). The deltas were mainly related to the work environment (equipment and maintenance) (p < 0.001) while the pluses identified tended to be related to the organization of the unit (communication and roles) (p < 0.001). With leadership's support and subsequent actions, clinicians were more enthusiastic about participating and the researchers anecdotally detected a switch toward a more positive organizational learning approach.ConclusionThe framework increases the potential value of clinical debriefings because it organizes results into actionable areas. Indeed, leadership found the DOLL to be a useful management tool. Further research is needed to investigate how DOLL may work in non-crisis circumstances and further apply the DOLL into incident reporting and risk management process of the unit.
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Affiliation(s)
- Méryl Paquay
- Department of Emergency, Quartier Hôpital, University Hospital of Liege, Liège, Belgium
- Center for Medical Simulation of Liege, Quartier Hôpital, University of Liege, Liège, Belgium
- *Correspondence: Méryl Paquay
| | - Nadège Dubois
- Center for Medical Simulation of Liege, Quartier Hôpital, University of Liege, Liège, Belgium
| | - Anh Nguyet Diep
- Biostatistics Unit, Quartier Hôpital, University of Liège, Liège, Belgium
| | - Gwennaëlle Graas
- Center for Medical Simulation of Liege, Quartier Hôpital, University of Liege, Liège, Belgium
| | - Tamara Sassel
- Center for Medical Simulation of Liege, Quartier Hôpital, University of Liege, Liège, Belgium
| | - Justine Piazza
- Department of Emergency, Quartier Hôpital, University Hospital of Liege, Liège, Belgium
- Center for Medical Simulation of Liege, Quartier Hôpital, University of Liege, Liège, Belgium
| | | | - Alexandre Ghuysen
- Department of Emergency, Quartier Hôpital, University Hospital of Liege, Liège, Belgium
- Center for Medical Simulation of Liege, Quartier Hôpital, University of Liege, Liège, Belgium
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12
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Kennedy-Metz LR, Barbeito A, Dias RD, Zenati MA. Importance of high-performing teams in the cardiovascular intensive care unit. J Thorac Cardiovasc Surg 2022; 163:1096-1104. [PMID: 33931232 PMCID: PMC8481338 DOI: 10.1016/j.jtcvs.2021.02.098] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 12/14/2022]
Affiliation(s)
- Lauren R. Kennedy-Metz
- Department of Surgery, Harvard Medical School, Boston, Mass,Division of Cardiac Surgery, VA Boston Healthcare System, Boston, Mass
| | - Atilio Barbeito
- Anesthesiology Service, Durham VA Health Care System, Durham, NC,Department of Anesthesiology, Duke University, Durham, NC
| | - Roger D. Dias
- Department of Emergency Medicine, Harvard Medical School, Boston, Mass
| | - Marco A. Zenati
- Department of Surgery, Harvard Medical School, Boston, Mass,Division of Cardiac Surgery, VA Boston Healthcare System, Boston, Mass
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13
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Domingues AN, Hilário JSM, de Mello DF, Parro Moreno AI, Fonseca LMM. Telesimulation about home visits and child care: facilitators, barriers and perception of Nursing students. Rev Lat Am Enfermagem 2022; 30:e3672. [PMID: 36629725 PMCID: PMC9818358 DOI: 10.1590/1518-8345.6037.3672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/27/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE to evaluate the facilitators, barriers and perceptions of Nursing students in learning about home visiting and child care through Telesimulation during the COVID-19 pandemic. METHOD a qualitative study to evaluate Telesimulation via computers, grounded on Kolb's theoretical model. A semi-structured questionnaire and the Student Satisfaction and Self-Confidence in Learning Scale were applied, with descriptive analysis and qualitative thematic analysis on the perceptions of 41 Nursing students. RESULTS the contextualized Telesimulation provided learning opportunities in dimensions of the pedagogical strategy, telesimulated scenario, communication and specificities of child care in home visits. It was considered a safe and dynamic activity that helped knowledge consolidation and reflective attitudes, proximity to reality, and develop interaction, observation and types of approaches. There were restrictions due to Internet connection failures. A large percentage of the students indicated good satisfaction and self-confidence level with learning in the scale applied. CONCLUSION the real clinical situation with remote immersion allowed observation, decision-making, reflection and elaboration of conclusions, inherent to the experiential learning cycle. The set of elements of this Telesimulation created an environment that stimulated the interest of Nursing students for other learning stages, suggesting a space that strengthens knowledge and maintains dialogue with face-to-face practices.
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Affiliation(s)
- Aline Natália Domingues
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
| | - Jeniffer Stephanie Marques Hilário
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil., Bolsista do Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil
| | - Débora Falleiros de Mello
- Bolsista do Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil., Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto, SP, Brazil
| | | | - Luciana Mara Monti Fonseca
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto, SP, Brazil
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14
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Domingues AN, Hilário JSM, Mello DFD, Parro Moreno AI, Fonseca LMM. Telessimulação sobre visita domiciliar e cuidado infantil: facilidades, barreiras e percepções de estudantes de enfermagem. Rev Lat Am Enfermagem 2022. [DOI: 10.1590/1518-8345.6037.3673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Resumo Objetivo: avaliar as facilidades, barreiras e percepções de estudantes de enfermagem na aprendizagem sobre visita domiciliar e cuidado infantil por telessimulação na pandemia da COVID-19. Método: estudo qualitativo avaliativo de telessimulação por computador, fundamentado no modelo teórico de Kolb. Foram aplicados um questionário semiestruturado e a Escala de Satisfação de Estudantes e Autoconfiança na Aprendizagem, com análise descritiva e análise qualitativa temática sobre percepções de 41 graduandos de enfermagem. Resultados: a telessimulação contextualizada proporcionou oportunidades de aprendizagem em dimensões da estratégia pedagógica, cenário telessimulado, comunicação e especificidades do cuidado infantil em visita domiciliar. Atividade segura e dinâmica, auxiliou a solidificar conhecimentos e atitudes reflexivas, aproximação à realidade, desenvolvimento da interação, observação e tipos de abordagens. Houve restrições por falhas de conexão. Grande parte dos estudantes indicou níveis bons de satisfação e autoconfiança com a aprendizagem na escala aplicada. Conclusão: a situação clínica real com imersão remota permitiu observação, tomada de decisão, reflexão e elaboração de conclusões inerentes ao ciclo de aprendizagem experiencial. O conjunto de elementos desta telessimulação criou um ambiente que estimulou o interesse dos estudantes de enfermagem para outras etapas de aprendizagem, sugerindo um espaço que fortalece conhecimentos e que guarda interlocução com as práticas presenciais.
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Affiliation(s)
| | | | - Débora Falleiros de Mello
- Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil; Universidade de São Paulo, Brazil
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15
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Domingues AN, Hilário JSM, Mello DFD, Parro Moreno AI, Fonseca LMM. Telesimulación en visitas domiciliarias y cuidado infantil: facilidades, barreras y percepciones de estudiantes de enfermería. Rev Lat Am Enfermagem 2022. [DOI: 10.1590/1518-8345.6037.3671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Resumen Objetivo: evaluar las facilidades, barreras y percepciones de estudiantes de enfermería en el aprendizaje sobre visita domiciliaria y cuidado infantil por telesimulación en la pandemia de COVID-19. Método: estudio cualitativo que evalúa la telesimulación por computadora, basado en el modelo teórico de Kolb. Se aplicó un cuestionario semiestructurado y la Escala de Satisfacción de los Estudiantes y Autoconfianza en el Aprendizaje, con análisis descriptivo y análisis temático cualitativo sobre las percepciones de 41 estudiantes de enfermería. Resultados: la telesimulación contextualizada brindó oportunidades de aprendizaje en los aspectos estrategia pedagógica, escenario telesimulado, comunicación y especificidades del cuidado infantil en visitas domiciliarias. Es una actividad segura y dinámica, que contribuyó a consolidar conocimientos y actitudes reflexivas, permitió un acercamiento a la realidad, el desarrollo de la interacción, observación y tipos de acercamientos. Hubo restricciones por fallas en la conexión. La mayoría de los estudiantes indicaron buenos niveles de satisfacción y confianza en sí mismos con el aprendizaje en la escala aplicada. Conclusión: la situación clínica real con participación a distancia permitió la observación, toma de decisiones, reflexión y elaboración de conclusiones inherentes al ciclo de aprendizaje experiencial. El conjunto de elementos de esta telesimulación creó un ambiente que estimuló el interés de los estudiantes de enfermería por otras etapas de aprendizaje, por lo que se considera un espacio que fortalece el conocimiento y dialoga con las prácticas presenciales.
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Affiliation(s)
| | | | - Débora Falleiros de Mello
- Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil; Universidade de São Paulo, Brazil
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Effect of after action review on safety culture and second victim experience and its implementation in an Irish hospital: A mixed methods study protocol. PLoS One 2021; 16:e0259887. [PMID: 34793495 PMCID: PMC8601442 DOI: 10.1371/journal.pone.0259887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 10/28/2021] [Indexed: 12/02/2022] Open
Abstract
Background After Action Review is a form of facilitated team learning and review of events. The methodology originated in the United States Army and forms part of the Incident Management Framework in the Irish Health Services. After Action Review has been hypothesized to improve safety culture and the effect of patient safety events on staff (second victim experience) in health care settings. Yet little direct evidence exists to support this and its implementation has not been studied. Aim To investigate the effect of After Action Review on safety culture and second victim experience and to examine After Action Review implementation in a hospital setting. Methods A mixed methods study will be conducted at an Irish hospital. To assess the effect on safety culture and second victim experience, hospital staff will complete surveys before and twelve months after the introduction of After Action Review to the hospital (Hospital Survey on Safety Culture 2.0 and Second Victim Experience and Support Tool). Approximately one in twelve staff will be trained as After Action Review Facilitators using a simulation based training programme. Six months after the After Action Review training, focus groups will be conducted with a stratified random sample of the trained facilitators. These will explore enablers and barriers to implementation using the Theoretical Domains Framework. At twelve months, information will be collected from the trained facilitators and the hospital to establish the quality and resource implications of implementing After Action Review. Discussion The results of the study will directly inform local hospital decision-making and national and international approaches to incorporating After Action Review in hospitals and other healthcare settings.
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Diaz-Navarro C, Leon-Castelao E, Hadfield A, Pierce S, Szyld D. Clinical debriefing: TALK© to learn and improve together in healthcare environments. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.1016/j.tacc.2021.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Stafford JL, Leon-Castelao E, Klein Ikkink AJ, Qvindesland SA, Garcia-Font M, Szyld D, Diaz-Navarro C. Clinical debriefing during the COVID-19 pandemic: hurdles and opportunities for healthcare teams. Adv Simul (Lond) 2021; 6:32. [PMID: 34526150 PMCID: PMC8441031 DOI: 10.1186/s41077-021-00182-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 08/24/2021] [Indexed: 01/26/2023] Open
Abstract
The COVID-19 pandemic and the subsequent pressures on healthcare staff and resources have exacerbated the need for clinical teams to reflect and learn from workplace experiences. Surges in critically ill patients, the impact of the disease on the workforce and long term adjustments in work and life have upturned our normality. Whilst this situation has generated a new 'connectedness' within healthcare workers, it also continues to test our resilience.An international multi-professional collaboration has guided the identification of ongoing difficulties to effective communication and debriefing, as well as emerging opportunities to promote a culture of dialogue. This article outlines pandemic related barriers and new possibilities categorising them according to task management, teamwork, situational awareness and decision making. It describes their direct and indirect impact on clinical debriefing and signposts towards solutions to overcome challenges and, building on new bridges, advance team conversations that allow us to learn, improve and support each other.This pandemic has brought clinical professionals together; nevertheless, it is essential to invest in further developing and supporting cohesive teams. Debriefing enables healthcare teams and educators to mitigate stress, build resilience and promote a culture of continuous learning and patient care improvement.
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Affiliation(s)
- Jody L Stafford
- Department of Perfusion/Cardiothoracic Surgery, Cardiff and Vale University Health Board, Cardiff, UK
| | - Esther Leon-Castelao
- Clinical Simulation Laboratory, Faculty of Medicine and Healthcare Sciences, University of Barcelona, Barcelona, Spain
| | - Albert J Klein Ikkink
- Wenckebach Simulation Center for Training, Education and Research, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Munt Garcia-Font
- Clinical Simulation Laboratory, Faculty of Medicine and Healthcare Sciences, University of Barcelona, Barcelona, Spain
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Kolbe M, Schmutz S, Seelandt JC, Eppich WJ, Schmutz JB. Team debriefings in healthcare: aligning intention and impact. BMJ 2021; 374:n2042. [PMID: 34518169 DOI: 10.1136/bmj.n2042] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Michaela Kolbe
- University Hospital Zurich, Simulation Centre, Switzerland
- ETH Zurich, Switzerland
| | - Sven Schmutz
- University Hospital Bern, Inselspital, Switzerland
| | | | - Walter J Eppich
- RCSI University of Medicine and Health Sciences, RCSI SIM Centre for Simulation Education and Research, Ireland
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Szyld D, Arriaga AF. Implementing clinical debriefing programmes. Emerg Med J 2021; 38:585-586. [PMID: 34039643 DOI: 10.1136/emermed-2021-211133] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/26/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Demian Szyld
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA .,Institute for Medical Simulation, Center for Medical Simulation, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander F Arriaga
- Harvard Medical School, Boston, Massachusetts, USA.,Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Ariadne Labs, Boston, Massachusetts, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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21
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Chen YYK, Arriaga A. Crisis checklists in emergency medicine: another step forward for cognitive aids. BMJ Qual Saf 2021; 30:689-693. [PMID: 33766892 DOI: 10.1136/bmjqs-2021-013203] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2021] [Indexed: 01/21/2023]
Affiliation(s)
- Yun-Yun K Chen
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Alexander Arriaga
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA .,Center for Surgery and Public Health, Boston, Massachusetts, USA.,Ariadne Labs, Boston, Massachusetts, USA
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22
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Seelandt JC, Walker K, Kolbe M. "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. Adv Simul (Lond) 2021; 6:7. [PMID: 33663598 PMCID: PMC7931165 DOI: 10.1186/s41077-021-00161-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/15/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Julia Carolin Seelandt
- Simulation Center, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Katie Walker
- New York City, Health + Hospitals Simulation Center, 1400 Pelham Parkway South, Building 4, 2nd Floor, Bronx, NY 10461 USA
| | - Michaela Kolbe
- Simulation Center, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland
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