From the Frontlines: A Qualitative Study of Staff Experiences With Clinical Event Debriefing

We conducted this study at a freestanding children’s hospital during February and March 2020. CED is practiced widely but with limited central oversight. We recruited clinical staff from the MBU and the N/IICU to allow for comparative analysis across patient populations and CED practices.

The MBU is a 10-bed unit for patients with a primary medical diagnosis whose comorbid mental health conditions require a higher level of psychosocial resources than traditionally available on a hospital ward. Accordingly, the MBU has dedicated psychosocial staffing (eg, unit psychologist) in addition to a general medical team of attending hospitalists and advanced practice providers (APPs).

The MBU practices 2 types of CED. Staff use hot CED to review behavioral crisis events. Implemented in 2017, this process takes place ∼2 to 3 times per month. A senior staff member (eg, charge nurse) typically leads the discussion, which is convened on an ad hoc basis through direct communication or use of the hospital’s phone and/or paging system. There is no required group composition, but participation is encouraged from all staff involved in the event. Typically, 3 to 8 staff members participate. The discussion is held at a distance from the patient’s room. The group uses a facilitative script, which serves as a data collection tool for unit leaders. The process is designed to take 5 to 10 minutes (Supplemental Figs 1 and 2).

Clinical staff also practice cold CED in the form of a scheduled, weekly 60-minute unit meeting. Implemented in 2019, this process is facilitated by a psychologist or senior staff member. The discussion is held in a private conference room and focuses on patients who have been hospitalized on the unit for >30 days. The primary goals of the meeting are to review patient behavior events (including any hot CED guides) and update care plans (Supplemental Figs 1 and 2).

The MBU’s CED guides were developed on the basis of process objectives and informed by the literature. The hot CED guide was adapted from the Mullan et al DISCERN tool.² 

The N/IICU is a 100-bed, level IV NICU that practices 2 forms of CED, implemented in 2013. A charge nurse or attending neonatologist leads hot CED after resuscitation events. This process takes place ∼1 to 2 times per month. Discussions are held at the patient’s bedside or elsewhere in the unit and are convened on an ad hoc basis through direct communication or use of the hospital’s phone and/or paging system. There is no required group composition, but participation is encouraged from all staff involved in the event. Typically, 5 to 10 staff participate. The group uses a facilitative script,²⁶  which serves as a data collection tool for unit leaders and was developed as part of a multicenter neonatal quality collaborative. The process is designed to take 5 to 10 minutes.

The N/IICU also uses cold CED to review a subset of complex resuscitations. Organized by the unit’s resuscitation committee, these 60-minute sessions take place monthly to bimonthly and involve review of relevant code sheets and hot CED guides. They are held in a private conference room and invite participation from unit leaders, staff involved in the event, and relevant subject matter experts. There is no dedicated guide for cold CED, but the hot CED guide is often used.

Clinical staff were eligible to participate in this study if they had attended a unit-based CED in the previous week. All MBU clinical staff were eligible. In the N/IICU, participation was limited to nurses and attending neonatologists; clinical trainees and other roles were excluded to minimize bias from learners and rotational staff. After a CED during the study period, investigators contacted each participant via phone or e-mail to solicit voluntary interest in study enrollment.

We developed a semistructured interview guide on the basis of the study objectives and informed by a review of the literature (Supplemental Information). For each study participant, we conducted a 30-minute interview within 1 week of CED attendance. Interviews were digitally recorded and then transcribed and deidentified by third-party transcription services (Datagain Enterprises, LLC; ADA Transcription).

We uploaded deidentified interviews into QSR NVivo 12 Plus Software (QSR International [Americas] Inc; Burlington, MA) for coding and analysis. Using content analysis with constant comparative coding, we developed a codebook to closely match priorities identified by participants.²⁷  During the coding process, investigators worked together to analyze transcripts to ensure consistent applications of the codes to the data. Disagreements were resolved by consensus and code definitions adjusted as needed. The coding team worked together to co-code a total of 15 (47%) interviews, establishing and maintaining a strong level of interrater agreement (⁠$κ>0.80$⁠). The remaining 17 interviews were divided and coded independently.

After the initial coding process, we used inductive reasoning to develop a set of CED practice recommendations to closely match priorities identified by participants.²⁷ 

The hospital’s institutional review board reviewed this study and determined it does not meet criteria for human subjects research according to 45 Code of Federal Regulations 46.102(d).

We conducted 32 semistructured interviews, representing 16 of 32 (50%) eligible MBU staff and 15 of 42 (36%) eligible N/IICU staff. Staff who did not enroll were generally unavailable during the interview period. One MBU respondent was interviewed twice after 2 distinct CEDs. Respondents represented a diversity of roles (Table 1) and were recruited after a mix of hot and cold CEDs (Table 2). We identified 3 major categories relevant to CED barriers and facilitators: factors that impact attendance, engagement, and learning and systems improvement (Table 3). From these, we identified several recommendations for CED practice (Table 4).

In both units, respondents cited timing relative to the event as an important determinant of CED attendance. They described the period after an acute event as busy but efficient for gathering participants for hot CED. However, this period may preclude participation from frontline providers if competing clinical duties are not absorbed by other unit staff. One respondent said, “I think the biggest barrier is that after a code, there’s still so much going on, especially for the bedside nurse…We’re not just like, we’re done here….” (N/IICU, nurse, hot CED).

N/IICU respondents also described timing as a determinant of cold CED attendance, citing the challenge of variable participant schedules. In contrast, MBU respondents spoke infrequently about scheduling challenges with cold CED, which takes place at a consistent time each week.

Respondents in both units spoke of the need for intentionality in driving CED attendance because staff rely on organizers to actively invite their participation. In particular, respondents emphasized the need to include frontline staff in CED. Several respondents felt that frontline attendance should be prioritized, despite conflicting duties. To this point, one MBU respondent suggested that a colleague temporarily cover a bedside nurse’s clinical duties to facilitate their attendance. As an alternative, some respondents suggested that supervisors serve as frontline delegates at the CED. One respondent commented, “…we encourage [psychiatric technicians] to give any feedback to somebody else who might be at the meeting, for example, a supervisor” (MBU, physician, Cold CED).

Several respondents also advocated for a broader approach to promote CED attendance among relevant stakeholders, such as an algorithm to ensure appropriate staff are notified (Table 3).

Several MBU and N/IICU respondents described that the CED group’s composition can influence how participants engage in reflective discussion. They cited the mix of disciplines (eg, how many nurses attend) as one important factor. Professional status was named as another key aspect. One respondent described the challenging dynamics for frontline staff who participate in CED alongside their clinical supervisor: “…the [psychiatric technician] supervisor was kind of monopolizing the conversation …I could see [it was frustrating] for the [frontline technicians] in the room…” (MBU, psychiatric technician, hot CED).

However, other respondents spoke positively about supervisor participation. One MBU respondent cited a desire for greater CED involvement by their supervisors. Supervisor participation was also cited as a positive factor across professional disciplines. One respondent said, “Just having like a [neonatology] fellow and attending’s perspective to say, ‘no, we think this is absolutely how you should have managed the situation,’ that was very helpful…” (N/IICU, nurse, hot CED).

Respondents highlighted the universal need for a CED environment in which participants feel they can speak up without fear of blame or judgment, the definition of a psychologically safe environment.²⁸  When asked about the most important part of the CED process, one respondent said, “I think that everyone can speak freely” (N/IICU, attending, hot CED).

Respondents described various factors impacting psychological safety in CED, including the mix of participants by roles and professional status. Many respondents also named the CED leader as a key determinant of participant comfort in speaking up, with several respondents highlighting the importance of inclusive leadership. One respondent said, “You can’t come in in any situation and say ‘I am now the lead. Listen to me.’ No, you need to build rapport. You need to have people buy into what you’re saying” (MBU, psychiatric technician, hot CED).

Use of a facilitative script was named as a strategy to promote psychological safety. Multiple MBU and N/IICU respondents described that a script can keep the group on track, which in turn encourages input from a variety of participants. However, several respondents warned that a script can alienate participants if their distinct priorities are not represented. One respondent stated, “…[the debriefing leader] didn’t really hit what I was gonna say, so it’s not really worth bringing up a whole ‘nother issue” (MBU, psychiatric technician, hot CED).

Indeed, many respondents described that the CED leader must actively facilitate the discussion to ensure participants feel supported in bringing up tough issues, whether they are reflected in the script or not. One respondent described a CED in which active facilitation was absent, leading to participant discomfort: “….[a participant] very bravely stated that something made her very uncomfortable… And then there was just a lot of silence afterwards… I think [the leader] should have addressed it…” (N/IICU, nurse, hot CED).

Ultimately, multiple MBU and N/IICU respondents acknowledged that CED may not be the right forum to address each participant’s priorities, particularly for staff who feel uncomfortable speaking up in a larger group. Instead, respondents in both units cited small group huddles as a useful vehicle for additional reflection.

A majority of respondents described that a shared mental model of both the patient and the event is necessary for high-quality CED because each participant has a potentially myopic perspective that may limit learning. They stressed that a comprehensive mental model requires a diversity of inputs from different roles. When asked about elements of the CED that they found most helpful, one respondent said, “I think just asking and having everyone’s perspective of what went well and what didn’t go so well…We don’t know everyone’s different levels of training so maybe there was miscommunication as to what should have happened versus what actually happened” (MBU, nurse, hot CED).

Many MBU and N/IICU respondents spoke about the importance of feedback in CED. They underscored the need to both reinforce effective behaviors and identify areas for improvement because both are valuable for learning. One respondent also cited the benefits of feedback for supervisors: “…[CED] is really beneficial for teamwork, particularly at the attending level because we don’t get feedback on our own performance with any type of regularity…” (N/IICU, physician, cold CED).

Several MBU and N/IICU respondents highlighted the need for the CED group to generate a plan for improvement. Respondents also described the importance of sharing the follow-up plan in a timely manner, a process that can be challenging after hot CED.

“I think that’s something that… is missing in [immediate CED]…like as a team or as a whole unit gets an email or something to say, this was what led to [the event] instead of waiting… Because… that same thing could happen if somebody isn’t aware….” (MBU, APP, hot CED).

Handoffs and small group huddles were commonly cited as potential strategies for sharing learnings in a timely manner. However, these strategies rely on staff accountability. One respondent said, “…it just relies on the accountability of individual people to spread the message and remember to spread it” (MBU, APP, cold CED).

Collectively, the priorities identified by respondents propose several recommendations for CED practice, including the intentional inclusion of frontline staff (Table 4).

In this study, we interviewed clinical staff from 2 inpatient units in a children’s hospital. We sought to characterize and compare staff experiences with CED. We identified 3 main categories relevant to CED barriers and facilitators, including factors that impact attendance, participant engagement, and learning and systems improvement, with substantial overlap in themes across units.

Staff described timing and intentional inclusion of participants as 2 important determinants of CED attendance. With hot CED, they referenced a need to balance patient care responsibilities in the aftermath of an event with the efficiency afforded by the preassembled group of staff at the bedside. Staff described similar issues with cold CED, which must accommodate conflicting clinical schedules.

Unfortunately, in both hot and cold CED, scheduling conflicts could invite bias if organizers do not plan for frontline representation, either directly or through a delegate. Indeed, without the frontline perspective, the CED group is limited in their ability to generate a shared mental model of the patient and the event. As a result, identified opportunities for learning or systems improvement may not reflect the expertise of key stakeholders, a prerequisite for success in any high-reliability organization.^29,30 

Importantly, staff highlighted that attendance is not synonymous with engagement in CED. They named various factors influencing participant engagement, including the CED leader, who must help cultivate a psychologically safe environment in which participants feel empowered to speak up without fear of blame or judgment. They also named the leader as being accountable for maintaining psychological safety even when it is threatened by participants. Indeed, respondents acknowledged that CED participants can influence psychological safety through either shared reflections or intrinsic professional characteristics. For example, professional status differentials among participants were cited as a potential threat to psychological safety. We might also speculate that some participants, such as frontline or junior staff, are more vulnerable to this threat, given psychological safety is positively associated with professional status.³¹  But intriguingly, our data suggest that status differentials could be viewed positively across professional disciplines. Perhaps CED participants welcome feedback from senior staff when there is not a perceived threat of performance evaluation.

Although proven strategies to promote psychological safety are not yet known,³²  staff named several factors that could promote psychological safety among CED participants. Staff described the positive effect of CED leaders who build rapport with participants and actively facilitate discussion, which can help participants feel supported in bringing up tough issues. Use of a facilitative script was named as another strategy, but the leader must recognize the limits of a script in addressing each participant’s priorities. Collectively, these strategies can invite participants to share a diversity of reflections, ones that are necessary for learning and, ultimately, systems improvement.

Our findings are consistent with a body of literature in organizational behavior that posits an important role for psychological safety in team reflexivity,^33–35 a concept that describes a team’s ability to reflect collectively on group objectives, strategies (eg, decision-making), processes (eg, communication), and outcomes of past performance and adapt accordingly.^36,37  Yet between reflection and adaptation, our data suggest that the CED group must generate a plan for improvement, with clear accountability for executing the plan.

We recognize that several of the themes identified in this study echo published findings in the CED literature. However, to our knowledge, this is the first study in which researchers compare the subjective experiences of CED participants in diverse care areas as a means of informing practice design. Furthermore, this is the first study in health care in which researchers provide insights into the relationship between psychological safety and the learning and improvement generated through CED.

This study is not without limitations. First, this is a single-center study that may have limited generalizability. Nurses were also overrepresented in this study, so our findings may not adequately capture the perspective of physicians and other roles, whose CED experiences could vary on the basis of training and role responsibilities. Moreover, although CED may include elements of psychological debriefing,^2,15  debriefings with a primary goal of emotional processing were outside the scope of this report. Additionally, we did not capture the perspective of non-CED participants, and we interviewed 1 subject on 2 occasions. These factors could bias our findings. We also did not account for factors that may impact how staff experience CED, such as age or years of experience.^17,38  Furthermore, we did not account for patient characteristics or the impact of CED on individuals or teams over time. Finally, we did not account for differences in CED timing, goals, group compositions, or use of scripts, which could impact practice.³⁹ 

In this qualitative study, we examined the CED experiences of clinical staff in 2 hospital units. Our findings propose CED recommendations that reflect participants’ first-hand experiences, including a desire for frontline staff inclusion. In future study, researchers will explore implementation of CED practice recommendations.

We thank Ms Carina Flaherty for her contributions to data collection and coding. The authors also thank Dr Joseph St Geme and the Chair’s Initiative Awards Committee for their institutional support of this project.