Each day, frontline health care providers are faced with a myriad of clinical challenges that have the potential to affect them on a professional and personal level. Clinical event debriefings (CEDs) provide opportunities for health care teams to collectively reflect on recent events to improve patient care and address the emotional needs of team members. Unfortunately, despite the proven association of CEDs with improved clinical outcomes in various contexts, studies have revealed that CEDs occur infrequently.1 These represent missed opportunities to positively impact patient and provider well-being in the workplace.
In this month’s Hospital Pediatrics, Galligan et al conducted a qualitative study to address this issue by interviewing clinical staff who had attended recent hot and cold CEDs to understand the barriers and factors that promote the effective performance of CEDs.2 Hot debriefings generally occur minutes to hours after an event, whereas cold debriefings occur days to weeks later. Previous researchers have surveyed clinicians on the barriers to performing hot CEDs with closed-ended survey choices.3–5 In these survey-based studies, the top-cited barrier to CEDs has primarily been time limitations. Other common barriers include a lack of training in CED facilitation, challenges with finding a suitable CED location, and insufficient leadership support for CED implementation. Galligan et al have taken an important next step in the field of CED research with their qualitative approach to better understand inpatient staff experiences during CEDs. Although timing of the CED was the first mentioned barrier to CED performance, Galligan et al also described several factors that promoted effective CED, including the intentional inclusion of involved staff, the encouragement of multidisciplinary participation, the establishment of a psychologically safe environment, the use of a shared mental model, timely feedback, and future planning of process improvements. By evolving the voice of the discussion on how to encourage CEDs from the advice of subject matter experts in previously published articles to the CED participants themselves, rich discoveries can emerge to guide CED implementation leaders in the design of their CED programs.1,6
Caring for Health Care Providers
Health care workers have voiced their desire to have more frequent, structured CEDs in their clinical settings.7–10 Although the primary goal of most CED programs is to focus on process improvement and education, recent literature suggests that CEDs may also help health care workers care for themselves by addressing some of the emotional issues that might contribute to clinician burnout.11–13 In one ICU setting, attending a CED was a coping strategy associated with a significant reduction in the risk of burnout compared with less adaptive strategies that increased the risk of burnout, such as drinking alcohol or venting emotion.11
Physician burnout can often be linked to moral distress that is rooted in systemic deficiencies within the health care system.14,15 Moral distress is defined as “ethically knowing the right thing to do but not being able to accomplish it due to institutional constraints.”15 In CEDs, a common theme in many of the “delta” (ie, what could be improved) comments relate to ineffective care processes, institutional policies that negatively impact care, lack of appropriate equipment, and other systemic constraints. By discovering these concerns in CEDs, documenting them to be shared with unit leadership, and ultimately getting the issues addressed, CEDs can help to decrease the moral distress of clinicians and potentially protect them from adverse emotional outcomes. In a recent multicountry, multidisciplinary survey of clinical team members in emergency settings, researchers found that 34% of respondents intended to leave their job because of moral distress; however, when the clinician felt valued by the team, the team leader acknowledged the team’s efforts and teams that debriefed after events, providers were less likely to leave their jobs.16 To address the distress of workers within health care, it is critical to accurately acknowledge the source(s) of the distress to determine where to direct resources for solutions. If the assumption of the root cause of burnout is within the individual, then individual solutions (eg, yoga, mindfulness, work-life balance, etc) might be most effective at addressing the problem. If “the source of distress [is] a broken system, not a broken individual,” then we should direct solutions, such as CED programs that are incorporated into a system’s quality and safety program, at addressing the systemic deficiencies in health care.14
A distinctly separate process from CED is critical incident stress debriefing (ie, psychological debriefing), in which trained mental health professionals work with individuals after traumatic events to limit posttraumatic stress symptoms. Although many CED tools incorporate an initial reactions phase (to elicit a sense of how individual staff members felt the event transpired), most CED programs are not designed for clinicians to manage strong emotional reactions after an event. A best practice in CED is to ensure that the facilitator, or other members present, can do an informal emotional needs assessment of their team and refer team members to appropriate supportive services if indicated (eg, a chaplain, social worker, or employee assistance program) or provide referral information. As was mentioned by a nurse in a hot debriefing in the Galligan study, and from our collective experiences implementing CED programs, this emotional response from teammates is often identifiable by CED facilitators. Although in some CED programs encouraging findings on the impact of CEDs on the emotional health of the debriefing participants has been noted,17,18 we need further research in this area.
Caring for Our Patients
Just as CED is not an end, in and of itself, CED programs should not be designed primarily to maximize the percentage of CEDs performed for a given condition. To do so might risk disrupting the balance between efficiency and thoroughness, with too much importance placed on the former.19 Even in this qualitative study of barriers to CED, as in the previous quantitative CED studies, the timing of how to debrief in the busy clinical environment was the first among many cited factors by the study authors. In a qualitative study on barriers to CEDs in surgery, one participant summed up the ranking of the most common barrier to CEDs as “Time is number one. Time is number two. Time is number three.”8 Other participants in that same study believed time was in fact an excuse and said, “you can find time—you always have time.”8 Despite the inevitable improvements that will occur in CED programs worldwide, we cannot imagine a future state in which the timing and “time cost” of conducting CED will not be a challenge in our busy clinical environments. If we can demonstrate the continued value of CED programs, through both the power of clinical effectiveness data as well as the humanization of telling individual patient stories, health care systems will soon reach a fundamental tipping point whereby leadership and accrediting organizations will mandate that CEDs are incorporated into routine care.
With these mandates must come the resources to run these CED programs: the time cost of two 10-minute team CEDs per week is often dwarfed by the multiple hours of time that CED champions and other leaders must invest in addressing the issues raised in the CEDs. If leaders can provide the allocated time for CED programs to demonstrate value, we believe frontline clinicians will find the value-added time to debrief in their busy schedules because as one clinician stated, “if I put it in the debriefing, I know it’s going to get attended to.”20 By making CEDs routine in the clinical setting after specified triggers, it will help to diminish the historical stigma that CEDs are performed only when something goes wrong. It is this stigma that potentially contributes to the avoidance of some CEDs, after events in which team communication breakdowns have occurred, in settings in which CED performance is optional.21
We foresee a future state whereby CEDs are not only performed after many patient events but are also effectively performed after every shift. Paul Batalden, one of the leaders in quality improvement science, stated that “everyone in healthcare really has two jobs when they come to work every day: to do their work and to improve it.”22 With dedicated CED researchers, CED implementation champions, and multilateral buy-in support from those in health care, we can achieve this ideal state. Alternatively, if we all do today’s work in the same way that we did it yesterday, our care for patients and each other will not change. Although all changes do not lead to improvement, all improvement requires change.23 Think about one of your recent clinical events that is still on your mind. Were there opportunities for improved care? Could your team have managed to spend several minutes to debrief so that future patients and teams could benefit from your shared experience? The participants in this study seem to suggest that the CED of your patient would have been feasible, valuable, and worthy of reflection. These participants spoke up during their CEDs to help improve care for their future patients while improving the workplace for their current team members.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.hosppeds.org/cgi/doi/10.1542/hpeds.2021-006088
References
Competing Interests
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
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