The debriefing toolkit – what are the necessary components?

Clinical debriefing occurs in many different contexts in acute healthcare, including after unexpected clinical deterioration, recognized safety events, and provider mistreatment/patient incivility. In these situations, the debrief is often intended as a forum for reflection and, ideally, both immediate and future improved interprofessional team communication, individual reflection and psychological restoration.1,2 Such debriefing differs from that included as a standard part of simulation exercises, where the timing and nature of the simulated situation can be predicted and the knowledge and skill development highlighted can be more easily standardized within the debrief.

Given their unpredictability, it is not surprising that there is inconsistent implementation of debriefs after acute clinical events.3,4 Especially in high acuity clinical setting, additional events for other patients may prevent a timely debrief.5 However, even when there is time and some team members may expect a debrief, senior personnel may assume that leading the debrief is their responsibility and yet feel uncomfortable or inadequately trained to lead these discussions.5 In at least some of those cases, the opportunities for a debrief may be ignored.

When debriefings actually do occur, there generally is a lack of standardization in how they are conducted.1 Such variation in timing and personnel comfort might suggest the use of tools to improve facilitation of debriefs. Recently, Phillips and colleagues performed a systematic review of such tools for debriefing unplanned clinical events in hospital settings6 using the ‘5 Es’ educational framework (Educated/Experienced facilitator, Environment, Education, Evaluation, and Emotions)1 and the Kirkpatrick model for evaluation of educational interventions.

The authors found 21 tools from several countries that met their inclusion criteria, with most being used in specific settings (such as the Emergency Department) or for specific clinical scenarios (such as cardiac arrest). Only one identified tool (‘TALK’) was specifically designed for multiple event types across a diversity of clinical settings. Importantly, all but one tool included criteria for initiating a debrief, including six that specifically stated ‘staff request’ could be an option. Additionally, some of the tools had been implemented and studied well – one tool achieved Kirkpatrick Level 3 outcomes (behavioural change), while seven others achieved Level 4 (organisational and/or clinical outcome changes).

As only one tool offers guidance for multiple types of clinical events across clinical settings, what best practices might be generalizable from the full set of tools? Phillips and colleagues scored each tool based on a system they developed, combining components from the ‘5 Es’ and their Kirkpatrick level of evidence of use. However,  practitioners and administrators thinking about how to encourage debriefing across diverse clinical settings might be even more interested in the authors’ more detailed analysis of components of the tools within each of the ‘5 Es’.

From a facilitator perspective, multiple different professions were recommended to lead the different debrief tools, including some (such as a clinical psychologist for a neonatal intensive care unit debrief protocol) that might not be readily available in many clinical settings. Although most tools were designed for facilitation by either doctors or nurses, two were designed for use by any team member. Most tools recommended debriefs soon after the event, with a duration of less than 10 minutes, and most were intended to be conducted in a private space away from where the event and ongoing clinical care occur. Commonly, the tools were introduced with reference to a ‘blame free’ or similarly worded psychologically safe environment, offered open discussion of emotions and reactions related to the event(s), deliberately engaged participants on the topics of both what went well and what could have been done better (in the article, termed ‘plus/delta’), had a process for identifying possible changes to be made, and a strategy for follow-up of participants’ well-being. Another notable point is what many tools lacked – very few described any process for implementing any identified changes, and more than half of tools specifically designed for adverse events did not include discussion of emotional responses to the event.

So, how do we build capacity for these components and spread structured debriefing practices more widely? An important step would be training more team members to feel capable of leading a debrief. Fortunately, the tools described required training periods of four hours or less, which improves the chances that a broad coalition of personnel could be trained in these techniques, even during their formal professional education. Having pre-identified debriefing facilitators embedded in acute clinical settings may help remove the barrier of perceived lack of skill that may prevent some team members from advocating for debriefs. Given that the vast majority of debriefing tools were designed and described in specific clinical settings however, work to increase the number of flexible tools that can be deployed across an institution or multiple clinical environments would be important to foster dissemination and standardization of responses. Flexibility of the tools would allow the debrief to address the most pressing concerns; for example, some debriefs may need to focus more on emotional responses, whereas others may need more emphasis on clinical processes. Having a shared structural framework for flexible debriefings across clinical settings would allow institutional leaders to promote debriefing and normalize such conduct. Ultimately, such efforts would help achieve the most important step – making clinical debriefing the expectation, not the exception.

Joel Boggan

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3. Sjöberg F, Schönning E, Salzmann-Erikson M. Nurses’ experiences of performing cardiopulmonary resuscitation in intensive care units: a qualitative study. J Clin Nurs 2015;24:2522–8.
4. Sandhu N, Eppich W, Mikrogianakis A, et al. Postresuscitation debriefing in the pediatric emergency department: a national needs assessment. CJEM 2014;16:383–92.
5. Spencer SA, Nolan JP, Osborn M, Georgiou A. The presence of psychological trauma symptoms in resuscitation providers and an exploration of debriefing practices. Resuscitation 2019;142:175–181.
6. Phillips EC, Smith SE, Tallentire V, et al. Systematic review of clinical debriefing tools: attributes and evidence for use. BMJ Quality & Safety. Published Online First: 28 March 2023. doi: 10.1136/bmjqs-2022-015464.

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