Clinical debriefing

OVERVIEW

Clinical debriefing refers to learning conversations that occur soon after clinical events and involve the frontline workers that took part in patient care.

• also know as “hot debriefing” or “proximal debriefing”

RATIONALE

Clinical debriefing aims to:

• Promote learning and reflection for individuals and teams
• Identify opportunities for improvements in workflows, processes, and systems by learning from frontline clinicians’ analyses of “work as done”

Clinical debriefing is distinct from critical incident stress debriefing (Rose et al, 2002; Twigg, 2020), which is a psychological intervention aimed at reducing reducing post-traumatic stress. However, clinical debriefing still has potential to benefit staff wellbeing by:

• Creating a supportive learning environment
• Developing a shared understanding of events among the clinicians involved
• Identifying the need for further support (e.g. opportunities for ongoing peer support or professional psychological support after the hot debrief)

TRIGGERS FOR CLINICAL EVENT DEBRIEFING

Standardisation of triggers for clinical debriefing is advantageous for the following reasons (Kessler et al, 2015):

• Alignment with organisational goals
• Allow staff to anticipate debriefs
• Increase debriefing frequency

Triggers should be driven by local needs and priorities.

• Note that different people or professional groups may disagree on what situations require a debrief. In practice it is often useful to have “staff member request” as trigger for considering clinical debriefing.

HOW TO PERFORM CLINICAL DEBRIEFING

Numerous approaches to clinical debriefing exist in the literature. In general they share steps such as the following:

• Preparation
  • Invite all staff involved in the event to take part in the debrief
  • Allocate hot debrief facilitator and scribe (usually best if it is someone other than the Team Leader during the clinical event to given them a break and risk of power hierarchies limiting discussion)
  • Identify time and location for hot debrief
  • Check staff readiness before starting the debrief
• Delivery of hot debrief (ideally <5-10 minutes duration)
  • Facilitator establishes psychological safety, objectives, and expectations for the hot debrief
  • Summary of the case/ situation (e.g. provided by team leader)
  • Select topic(s) for discussion
  • Things that went well? Why? (“plus”)
  • Opportunities to improve? Why? (“delta”)
  • Points for action and key learnings (“take homes”)
• Post-debrief
  • Ensure action points are addressed and specifically allocated to individuals to follow up
  • Ensure that documentation is completed

Coggins et al (2020) identified 12 tips for clinical debriefing:

• Formulate criteria regarding when, and when not to initiate a clinical debriefing. (“Triggers”)
• Demonstrate and articulate the importance of debriefing to colleagues.
• Ensure a range of suitable environments for debriefing.
• Focus on the learning environment and emphasise psychological safety.
• Engage local faculty who can facilitate but not dominate (“guide on the side” not “sage on the stage”)
• Establish an implementation strategy aligned with local culture (e.g. “universal participation welcome, but not mandatory”).
• Use an easily recognisable structure for both facilitators and learners (see examples of tools below)
• Limit discussion topics and translate any important findings into meaningful clinical changes. (focus on selected topics and discuss the “why and how” as well as the “what”)
• Provide debriefers opportunities to improve their facilitation skills.
• Minimise the impact of hindsight bias and avoid individual assessments of performance. 
• Share a clear plan for providing expert help to distressed participants.
• Account for any legal issues and provide a policy on written documentation.

Examples of tools described in the literature to help guide clinical debriefing conversations:

• DISCERN (Mullan et al, 2015)
• INFO (Rose & Cheng, 2018)
  • immediate, not for personal assessment, fast facilitated feedback, and opportunity to ask questions
• STOP / STOP5 (Walker et al, 2020)
  • Summarise, things that went well, opportunities to improve, points to action and responsibilities
• TALK
  • Target, Analysis, Learning points, Key actions

Kessler et al (2015) provide a useful guide to how to implement a clinical debriefing programme.

PROS AND CONS

Advantages

• Literature supports a desire among clinical staff to debrief critical events (Twigg, 2020)
• Role modelling of learning culture
• Improve staff morale and team cohesion
• Offsets the need for resource-intensive simulation-based learning
• Safe (no reports of harm from over 300 clinical debriefs – Rose & Cheng, 2018)
• Increased interprofessional learning in the workplace
• Identifies opportunities for systems improvements
• Can be effectively led by senior nurses using a script (Rose & Cheng, 2018)
• Allows adaptation in times of rapid practice change, such as the COVID19 pandemic (Stafford et al, 2021).

Disadvantages 

• Debriefing after clinical events is infrequent (Arriaga et al, 2020)
• Requires a culture of psychological safety
• Require planning, a suitable space, and time out of clinical work despite “production pressure” (Arriaga et al, 2020)
• Not everyone involved may buy in – lack of belief in the value of debriefing
• Interpersonal factors and communication breakdowns during an event (e.g interpersonal conflict) make clinical debriefing less likely to occur (Arriaga et al, 2020)
• Potential for conflict among participants during debrief
• Requirement for trained facilitators (Arriaga et al, 2020)
• Historical concern of harm from post-traumatic stress disorder for compulsory psychological debriefing for psychological distress (Rose et al, 2002) – however, no harm has been reported from clinical debriefing

COMPARISON TO COLD DEBRIEFS

A “cold debrief” is a delayed debrief that occurs days or weeks after a clinical event (Twigg, 2020). 

• cold debriefs allow more data to be collected, additional staff may be able to attend, expert facilitators may be available, and staff have had a chance to reflect
•  However, compared with “hot debriefs”  the events may not be clearly recalled by participants, some participants may not be able to attend, immediate support for staff is not provided, and learning from the event may be delayed. 

Cold debriefs are best viewed as complementary to hot debriefs, and may be informed by the hot debrief.

EVIDENCE

Direct evidence for the effectiveness of clinical debriefing is lacking, but can be inferred from the following:

• A systematic review of after action reviews across diverse workplaces found debriefing improved team and individual performance by 20-25% (Tannenbaum & Cerasoli, 2013). 
• A systematic review supported the use of use of structured debriefing as an educational strategy to improve clinician knowledge and skill acquisition and implementation in the intensive care setting (Couper et al, 2013).
• Numerous studies link clinical event debriefing programmes with improved performance and/or outcomes as part of targeted quality improvement initiatives (e.g. surgical safety, cardio-pulmonary resuscitation, and intubation) (Twigg, 2020)
• A systematic review of simulation-based debriefing showed that it improves knowledge, skills, and behaviour with patients and effects on patients. (Cheng et al, 2014)

REFERENCES AND LINKS

FOAM and web resources

• AHA — Hot Debriefing Form Examples (PDF links available here: http://www.heart.org/HEARTORG/Professional/GetWithTheGuidelines/GetWithTheGuidelines-Resuscitation/Get-With-The-Guidelines-Resuscitation-Clinical-Tools_UCM_314499_Article.jsp – .WX_PW9OGOL1)
• ANZCA — Critical Incident Debriefing Toolkit (2021)
• Debrief2Learn — Podcast 005: Clinical Debriefing (2017)
• Edinburgh Emergency Medicine – “STOP 5:Stop for 5 minutes” – Our bespoke hot debrief model (2018)
• INTENSIVE – ​​Amazing And Awesome ‘Hot’ Debriefs for Critical Incidents (2017)
• LITFL SMILE2 – Simulation debriefing (2021)
• St Emlyns — It’s Good to Talk – Debrief in the Emergency Department (2013)

Journal articles

• Arriaga AF, Szyld D, Pian-Smith MCM. Real-Time Debriefing After Critical Events: Exploring the Gap Between Principle and Reality. Anesthesiol Clin. 2020;38(4):801-20. https://doi.org/10.1016/j.anclin.2020.08.003. Epub 2020 Oct 13. PMID: 33127029; PMCID: PMC7552980
• Brazil, V., Symon, B. and Twigg, S. (2021), Clinical debriefing in the emergency department. Emergency Medicine Australasia, 33: 778-779. https://doi.org/10.1111/1742-6723.13834
• Coggins, A., Zaklama, R., Szabo, R., Diaz-Navarro, C., Scalese, R., Krogh, K., & Eppich, W. (2020). Twelve tips for facilitating and implementing clinical debriefing programmes. Med Teach. https://doi.org/10.1080/0142159X.2020.1817349
• Coggins A, Santos AL, Zaklama R, Murphy M. Interdisciplinary clinical debriefing in the emergency department: an observational study of learning topics and outcomes. BMC Emerg Med. 2020 Oct 7;20(1):79. doi: 10.1186/s12873-020-00370-7. PMID: 33028206; PMCID: PMC7542715. [article]
• Couper K, Salman B, Soar J, Finn J, Perkins GD. Debriefing to improve outcomes from critical illness: a systematic review and meta-analysis. Intensive Care Med. 2013;39(9):1513–23. https://doi.org/10.1007/s00134-013-2951-7.
• Kessler DO, Cheng A, Mullan PC. Debriefing in the emergency department after clinical events: a practical guide. Annals of emergency medicine. 2015; 65(6):690-8. [pubmed]
• Rose S, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database Syst Rev. 2002;(2):CD000560. doi: 10.1002/14651858.CD000560. PMID: 12076399. [article]
• Stafford, J.L., Leon-Castelao, E., Klein Ikkink, A.J. et al. Clinical debriefing during the COVID-19 pandemic: hurdles and opportunities for healthcare teams. Adv Simul 6, 32 (2021). https://doi.org/10.1186/s41077-021-00182-0
• Tannenbaum SI, Cerasoli CP. Do Team and Individual Debriefs Enhance Performance? A Meta-Analysis. Hum Factors. 2013;55(1):231–45. https://doi.org/10.1177/0018720812448394.
• Twigg S. Clinical event debriefing: a review of approaches and objectives. Curr Opin Pediatr. 2020 Jun;32(3):337-342. doi: 10.1097/MOP.0000000000000890. PMID: 32332325. [pubmed]
• Walker CA, McGregor L, Taylor C, Robinson S. STOP5: a hot debrief model for resuscitation cases in the emergency department. Clin Exp Emerg Med. 2020;7(4):259-266. doi:10.15441/ceem.19.086