Debriefing is defined as a directed, intentional conversation that can be used for knowledge or skill attainment, or to answer questions about threats to patient safety and patient care based on a recent event or a hypothetical situation. Debriefing has traditionally been used as part of simulation-based training in high stakes industries such as human health care and aviation. However, it’s utility scopes beyond simulation training, and has become an integral part of clinical practice in human healthcare.

Debriefing is broadly classified into 3 categories:

1.  Hot debriefing - e.g., immediate clinical debriefing

2.  Warm debriefing - e.g., at the end of shift

3.  Cold debriefing - e.g., scheduled morbidity and mortality rounds

This lecture will focus on hot clinical debriefing; however, tools and techniques from this lecture can also be utilised in other forms of debriefing.

Ultimately, the goal of debriefing is to improve patient outcome. This is not only dependent on knowledge and technical skills, but also on human factors including non-technical skills, hospital systems and ergonomics. Keeping this in mind, debriefing should take a learner-centered approach for clinical staff. One of the benefits of debriefing, is that it encourages reflective learning, part of Kolb’s experiential learning cycle. Reflective learning promotes self-directed learning and assessment, encourages attitude and behavioural change, which as a result improves performance, organisational change, and patient outcomes. Debriefing identifies areas of potential growth and improvement within a hospital, which is an integral part of hospital and institutional quality improvement processes. And finally, debriefing helps towards developing a safety culture within a hospital. Safety culture includes having a ‘just’ culture, learning culture, flexible culture, reporting culture, and informed culture. By undertaking regular quality debriefing, it will improve your hospital and institutions safety culture and patient outcome.

Clinical debriefing (a form of hot debriefing) is performed immediately after an event, and should be a short, focused debrief on less-controversial content and discusses team, rather than individual performance. Anything controversial or heavily involving hospital systems should be directed towards a cold debrief during morbidity and mortality rounds. Any severe critical incident in which a staff member may be distressed by should be addressed as a critical incident debrief, focusing on the psychological safety of the staff members, as a cold or warm debrief.

Now that we have a general concept on the purpose of clinical debriefing, we need to ask ourselves, ‘what’ should we actually debrief? You could consider different events which would trigger a debrief, which could include certain presenting complaints (e.g., on every cardiac arrest, every ventilator patient); final diagnosis (e.g., every septic shock); acuity level; location (e.g., ICU); level of complication (e.g., near-miss or patient harm); or interpersonal interactions (e.g., upset client, interdepartmental transfers). You may encounter a complicated case which you want to debrief which has many layers, however, focus on one or two aspects of the case to keep the debrief focused. Consider non-technical skills such as teamwork and communication, as well as technical skills. And focus on team performance rather than individual performance. Another rabbit hole people can get into is focusing too much on systems errors, which a cold debrief by the quality improvement committee or M&M rounds may be more appropriate. Digging too deep into systems error can create negative attitudes within a hospital, and deters from the ‘learning objective’ of the debrief.

Location of debriefing should also be carefully considered. Debriefing in the clinical area of the event has the benefit of being immediately without people dispersing, and can help discuss issues associated with equipment or procedures, giving opportunities to practice techniques or experimenting with improved equipment location or design. Debriefing in a separate room has it’s benefit of providing privacy for learners and patients, allowing tension to diffuse if it was a high stress event, and limits distractions; however, this space may not be available in busy hospitals.

Multidisciplinary (e.g., anaesthetist, criticalist, surgeon) and multi-professional (e.g., nurses, animal care attendants, triage team, vets) debriefing should be encouraged. Debriefing can be vet or nurse led, and not necessarily need to be the most senior staff member. Ideally, facilitators should be trained in debriefing, though this is not always possible. Therefore, there are simple designed and validated debriefing tools available to be used even by the most novice debriefer (see below on debriefing tools). If training is limited, co-debriefing with a more experienced debriefer should be considered, followed by a debrief on the debriefing (called meta-debriefing). Facilitators should be guiding a conversation allowing for reflective learning, rather than giving advice. The conversation should be focused on teamwork, rather than individual performance. A good facilitator will not only discuss ‘what’ happened, but also lead the conversation on the ‘whys’ (e.g., Sally was a good leader. => What areas of Sally’s leadership skills made this a successful CPR? => Sally led the CPR well because she had identified and clearly coordinated the roles of each individual participant). Another important role of the facilitator is to ensure psychological safety of the staff, by being aware of the participants emotions and non-verbal cues; being conscious of hindsight bias; creating a non-hierarchical conversation; being a humble lead acknowledging own limitations; and encouraging everyone to speak in a non-judgmental environment.

One of the most important goals of clinical debriefing is creating a safe space for open discussion, ensuring psychological safety for all participants. Psychological safety is defined as a person’s sense that the immediate environment is safe for interpersonal risk taking; and allows making mistakes without consequences. It creates a safe space to share and acknowledge each other’s experiences and feelings, which may be mutual but often unspoken between staff. It is important to carefully select the most appropriate events to debrief on, as if the event is to distressing, participants may not be ready to discuss the event immediately. A warm debriefing or one-on-one debriefing may be more appropriate in such situations. It is important to maintain psychological safety during the debrief by reminding participants of the ground rules (mutual respect) and objectives (learning outcomes), being aware of participants verbal and non-verbal cues, having a non-hierarchical team discussion, being aware of hindsight bias and careful facilitation of conversations. It is important to also focus on what went ‘right,’ which is known as ‘Safety-II.’

Phrases which can be used to encourage safety-II discussions can include:

• ‘Why did X go so well in this case?’
• ‘How can we ensure this happens again in the future?’
• ‘How did people adapt to overcome challenges in this case?’
• ‘Are there strategies that were used in this case to make work more efficient/effective?’
• ‘Were there any near misses? If so, how did the team adapt to prevent harm from occurring?
• ‘What is needed to ensure this happens reliably again in the future?’

Using a validated debriefing framework is important in having a structured and efficient debrief. A hot debrief should take no more than 5–10 minutes. There are many debriefing frameworks available, however, many of them focus on a debriefing framework for simulation based, rather than a clinical debrief (e.g., Diamond debriefing), which is often more in depth and takes longer to undertake. However, more recently on the floor clinical debriefing tools have been developed and validated in the human healthcare sector. The most commonly used framework and simple framework is ‘plus-delta’ debrief, which involves firstly discussing ‘what went well,’ followed by ‘what could be improved.’ Other debriefing frameworks have been validated for use including ‘STOP₅,’ ‘TEAM,’ ‘SHARP,’ ‘GREAT,’ and ‘CIRCLE UP.’ Some of these frameworks use an integrated approach (e.g., incorporating ‘Plus-Delta’ into ‘STOP₅’). Many of these validated debriefing tools have toolkits and forms available on-line which can help facilitate the debrief by novice debriefers. Have these toolkits/forms readily available in the emergency room for easy use, and use these forms to steer the conversations during a debrief.

Once a debrief is completed, it is important to ensure the debrief is followed up. Ensure all staff members feel safe after the debrief, and follow up any participants who you may be concerned about. A ‘distress protocol’ may be handy to help staff members after a critical incident, with resources for further professional help (e.g., free telephone counseling). If you have used a debrief toolkit, ensure the form is completed and lodged in a dedicated location (e.g., a tray, scanned into a digital folder, data entered into a spreadsheet). Have a system in place to follow up action points which may be raised from the debrief. Having a debrief champion and a quality improvement committee can help.

So, I have now convinced you to integrate debriefing into clinical practice. What do you need to do to get this off (or rather ‘on’ the floor?). Involve important stakeholders, such as senior management, quality improvement groups, clinical directors, head nurses, and education teams. Before launching a program, inform the hospital of the purpose of clinical debriefing which will be taking place, and lay down the ground rules and objectives. This can be done in the form of a meeting, email, or newsletter.

Important ground rules can include mutual respect and blame free conversations; time keeping; following a framework and filling out a form for follow up. As mentioned above, have a system in place for follow up of action points, and communicate the resolution of action points to the hospital staff, for example in the form of a regular newsletter, email, or updated protocols. This can help demonstrate positive outcomes from the debrief, and encourage others to continue debriefing.

References

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2.  Cheng A, Eppich W, Epps C, et al. Embracing informed learner self-assessment during debriefing: the art of plus delta. Adv Simul. 2021;6(22):1–9.

3.  Coggins A, Zaklama R, Szabo R, et al. Twelve tips for facilitating and implementing clinical debriefing programmes. Med Teach. 2021;43(5):509–517.

4.  Jainth R. Dynamic plus-delta: an agile debriefing approach centred around variable participant, faculty and contextual factors. Adv Simul. 2021;6(35):1–9.

5.  Kessler D, Cheng A, Mullan P. Debriefing in the emergency department after clinical events: A practical guide. Ann Emerg Med. 2015;6(65):690–698.

6.  Mullan P, Wuestner E, Kerr T, et al. Implementation of an in situ qualitative debriefing tool for resuscitations. Resuscitation. 2013;84:946–951.

7.  Sha P, Havalad V. A novel code team leader card to improve leader identification. J Patient Cent Res Rev. 2021;8(4):354–359.

8.  Szyld D, Arriaga A. Implementing clinical debriefing programmes. Emerg Med J. 2021;38:585–586.

9.  Walker C, 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.