There is so much I could write about the role and value of our own humanity in the Emergency Department although much of it has been said before by people far wiser than me. But there are situations when we are caught offguard; when things don’t go as we had hoped, or when they do -but a powerful and unexpected emotional reaction is evoked. For many of us, as Emergency Department stalwarts, we habitually brush off emotion to focus on our literally clinical day-to-day lives. But failing to acknowledge the value and importance of our intuition and reactions in challenging situations exposes us to cognitive bias and we should learn to use our emotion to moderate our logical side.
I’ve talked previously about the potential value of debrief after stressful situations, a concept being used and analysed more with the acceptance of the impact of human factors and the evolution of high-fidelity simulation training (although it remains controversial to some extent). But is there a best way to run a debrief in this situation?
[DDET “When to Debrief”]
There are three situations where debrief has potential value; after simulation, as a regular scheduled event, or after a critical incident. I should explain at this point that much of the literature refers to “critical incident” debrief in a broader sense than the NHS definition, encompassing situations where thing have gone wrong but also those difficult and unexpected times such as cardiac arrests, critically ill patients or difficult relatives. I’m mainly talking about these “critical incidents” below.
Informal debrief generally happens almost immediately after any uncomfortable clinical experience as we decompress to our colleagues in the coffee room. For formal debrief it is helpful to allow some time to pass; most debriefs are undertaken within a week of the event itself. The cost of this delay, particularly in the inevitably shift-based ED, is attendance levels among the staff.[/DDET]
[DDET “Why Debrief?”]
It is important to allow people to talk about and make sense of emotional and psychological responses to stressful situations. Reflecting on their impact on decision-making and on other team members can build stronger team relationships and enable modification of unhelpful behaviours. It is also essential to recognise that the effects of these situations extend beyond the Emergency Department itself.
Identifying areas for practice improvement
Even in successful resuscitations areas for improvement can usually be identified. Simple stock issues, for example, may go unnoticed by senior members of the medical team but cause the most frustration among nursing staff. Allowing time for all members of the team to highlight areas for improvement can generate meaningful and shared objectives for change.
Identifying areas of good practice
Again, even in resuscitations where everything seemed to go wrong, there is usually good practice. Consider the oft-talked-about, tragic case of Elaine Bromiley – of course, there is much to learn from this situation and the human factors involved – but has anyone stopped to praise the nurse for bringing the surgical airway trolley? Positive reinforcement is as important as recognising areas for improvement.
The rest of the story
We often joke that the Emergency Department suits our short attention span but I have argued before that not knowing what ultimately happens to the patients we care for divorces us from an ability to care. Debriefing a few days after the event can fill the gaps and provide a perspective of ED care we are not always privy to.
[DDET “Barriers to Debrief”]
Before starting a debrief, it’s important to be aware of the potential barriers to meaningful discussion.
- Criticism of own department: There is a natural reticence towards being too critical of our daily working environment, but the debrief must be a safe place for concerns to be raised. In the era of Francis the ability to speak freely on matters of clinical concern is paramount. Consider carefully whether staff not directly involved in the event itself should attend.
- Emotion vs facts: Beware allowing emotion to overshadow or colour “facts” of the event; agreeing a shared account of the facts in the first instance can help to maintain control
- Power balance: Consider the seniority and status of the debrief facilitator. Junior staff of any discipline must be able to speak freely without wondering “can I say this in front of him/her?” Every effort should be taken – including explicit explanation – to ensure that even the “formal” debrief is comfortable and relaxed
- Availability: Staff should be released from clinical duties to attend the debrief. An immediate debrief will usually capture all staff involved; a later debrief will usually mean that at least one or two staff cannot attend. While this may be unavoidable it is important to offer non-attendees the chance to talk about their own perceptions and to contribute to the debrief, potentially by secure email or written statement as appropriate.
[DDET “Top Tips”]
Below I’ve paraphrased 12 tips on debrief published in the Joint Commission Journal on Quality and Patient Safety.
- Decide on the purpose of the debrief – regular event versus critical incident
- Create a supportive learning environment and set ground rules
- Encourage attention to teamworking processes (think of the human factors you might identify were this simulation rather than real life)
- Train team leaders in debrief (an EMJ article found only 13% of those attending a debrief after failed paediatric resuscitation had received any training on debriefing)
- Ensure an appropriate, comfortable and private environment
- Focus on a few critical performance issues – don’t overwhelm
- Describe teamwork interactions and processes
- Support feedback with objective performance indicators
- Give more feedback on processes than on outcomes
- Balance individual with team oriented feedback
- Shorten delay between task and feedback as much as possible
- Record conclusions and goals/objectives for change
[DDET “How to Debrief”]
My favourite model for debrief is below; it comes from the International Critical Incident Stress Foundation and can be found here.
It describes a step-by-step framework for semi-structured discussion which I have adapted a little for the Emergency Department.
Introduction and groundrules
Individual introductions and explanation of roles, plus explicit explanation of the purpose of debrief and the safe environment – think Chatham House rule
Facts (describe what happened)
This is probably best done in a chronological manner; a timeline can be recorded if helpful. Facilitate the group to describe and agree an account of factual events
Thoughts (personalise the processes)
Facilitate discussion about thinking processes; if something went wrong, ask what participants were thinking at that moment and why. This can include verbalised emotional responses (“I just felt so helpless”) or clinical decisions (“I remember thinking that the blood pressure was the most important thing”)
Reaction (what bothered you most and why)
This offers participants the opportunity to express and deal with pervading thoughts about the event. There is often a single issue, image or event each person dwells on, and understanding why this has provoked a response is thought to be key to breaking the cycle of flashbacks to the event
Symptoms (evolution of feelings and reactions/flashbacks since event)
In “victims”, this step is used to discuss the evolution of feelings in the time that has passed since the event with focus on PTSD symptoms. In healthcare professionals, it might help to discuss coping strategies; “what did you do after the shift? Did that help? How did you feel the next morning? Do you feel the same today?”
Teaching & Learning from Events
The step of identifying areas for change is paramount; good practice can also be highlighted here. Making practical changes from a tangle of thoughts and emotions helps the participants not only to move on from the past event but to effect behaviour change for future events.
Re-entry (questions, summarise & follow-up plans)
Closure is important; an opportunity to ask questions is especially useful for junior staff who may still not know why or how a particular action or decision was taken. A summary of action points should be agreed by the group and ideally allocated for action.
And, of course, staff who need more support need to know where to turn. If this is you, there are always people willing to listen; your colleagues, partner, educational supervisor, clinical director, foundation tutor, friendly registrar, occupational health doctor, GP, the BMA to name but a few. Don’t keep it to yourself.
A similar structure might be employed on a one-to-one basis in the situation of debriefing a junior after a clinical error. These situations can be just as traumatic as a failed cardiac arrest and warrant careful handling to ensure that meaningful learning takes place without causing lasting damage to the trainee.
[DDET “Some Alternative Models”]
Below are some other models which might be of use
DISCERN model for immediate feedback