The Use of The Use of Debriefings for Debriefings for

Caregiver Stress Caregiver Stress

Marcie Peterson, MSN, RN, CCRN, CNMLMarcie Peterson, MSN, RN, CCRN, CNML

Children’s Hospital & Medical CenterChildren’s Hospital & Medical Center

April 16April 16thth, 2012, 2012

Have you ever…Have you ever…

Struggled with leaving work at workStruggled with leaving work at work

Performed a clinical assessment Performed a clinical assessment

Lost a patientLost a patient

Become too attachedBecome too attached

Felt like you were doing more harm Felt like you were doing more harm than goodthan good

As Nurses… As Nurses…

Repeated exposureRepeated exposure

Hear the stories by those we helpHear the stories by those we help

We absorb other people’s lossesWe absorb other people’s losses

Comfort our patients & families in need Comfort our patients & families in need

“The expectation that we can be immersed in suffering and loss and not

be touched by it is as unrealistic as expecting to be able to walk through

water without getting wet.”

~ Rachel Naomi Remen, 1996

How does all of this How does all of this affect us?affect us?

Work EnvironmentWork Environment

TeamTeam

Experience levelExperience level

RelationshipsRelationships

Spiritually Spiritually

How do we COPE???How do we COPE???

DebriefingDebriefing

A conference or discussion held with A conference or discussion held with the team after an intense event or the team after an intense event or catastrophe; all aspects of the event catastrophe; all aspects of the event are discussed and analyzedare discussed and analyzed

A process where support is given to A process where support is given to groups or individuals who have groups or individuals who have experienced an extraordinary clinical experienced an extraordinary clinical event that has the potential to cause event that has the potential to cause unusually strong emotional reactionsunusually strong emotional reactions

History History

Developed by Jeffrey T. Mitchell in 1974Developed by Jeffrey T. Mitchell in 1974

First used with small groups of First used with small groups of paramedics, firefighters, and law paramedics, firefighters, and law enforcement officersenforcement officers

Over time, debriefings spread to the Over time, debriefings spread to the military services, airlines, railroads, and military services, airlines, railroads, and hospitals hospitals

The Importance of The Importance of DebriefingsDebriefings

Patient Safety Patient Safety Clear thinking is essential for overcoming the Clear thinking is essential for overcoming the

chaotic and stressful environment in which chaotic and stressful environment in which patient care teams operatepatient care teams operate

Shared Understanding Shared Understanding Has developed during debriefings to improve Has developed during debriefings to improve

team performanceteam performance

Gained InsightGained Insight Use knowledge from past experience to Use knowledge from past experience to

improve future performance improve future performance

The Importance of The Importance of DebriefingsDebriefings

GuiltGuilt Individual team members may feel responsible Individual team members may feel responsible

for the eventfor the event

Coping SkillsCoping Skills Teams learn practical applications to assist in Teams learn practical applications to assist in

dealing with difficult situations in the futuredealing with difficult situations in the future

CommunicationCommunication Teams can develop new communication Teams can develop new communication

methods or strategies to use during methods or strategies to use during subsequent events. subsequent events.

12 Evidence-Based Best 12 Evidence-Based Best Practices Practices

1.1. Must be diagnosticMust be diagnostic

2.2. Create a supporting learning environmentCreate a supporting learning environment

3.3. Encourage team to be attentive of teamwork Encourage team to be attentive of teamwork process during performanceprocess during performance

4.4. Educate Facilitators/Leaders on the Art & Educate Facilitators/Leaders on the Art & Science of leading debriefingsScience of leading debriefings

5.5. Team members feel comfortableTeam members feel comfortable

6.6. Focus on a few critical performance issuesFocus on a few critical performance issues

Joint Commission Journal on Quality and Patient Safety, 2008Joint Commission Journal on Quality and Patient Safety, 2008

12 Evidence-Based Best 12 Evidence-Based Best Practices Practices

7.7. Describe specific teamwork interactions & processesDescribe specific teamwork interactions & processes

8.8. Support feedback with objective indicators of Support feedback with objective indicators of performanceperformance

9.9. Provide outcome feedback later and less frequently Provide outcome feedback later and less frequently than process feedbackthan process feedback

10.10. Provide both individual & team-oriented feedbackProvide both individual & team-oriented feedback

11.11. Shorten the delay between task performance and Shorten the delay between task performance and feedbackfeedback

12.12. Record conclusions made and goals set Record conclusions made and goals set

Joint Commission Journal on Quality and Patient Joint Commission Journal on Quality and Patient Safety, 2008Safety, 2008

Goals to Conduct a Goals to Conduct a DebriefingDebriefing

Identify the nature of the problemIdentify the nature of the problem

Review why…how…and what resultedReview why…how…and what resulted

Allow team members to discussAllow team members to discuss The decisions made during the eventThe decisions made during the event What could have been done differentlyWhat could have been done differently

• MiscommunicationMiscommunication• Unprofessional behaviorUnprofessional behavior

The need for remediation or trainingThe need for remediation or training Identify success and the positives which came Identify success and the positives which came

out of the eventout of the event

TimingTiming

Timing is Timing is ESSENTIALESSENTIAL!!!!!! Should occur shortly after the incidentShould occur shortly after the incident Within 24 to 72 hours Within 24 to 72 hours

Tools Used for Tools Used for DebriefingsDebriefings

Critical Incident Stress DebriefingCritical Incident Stress Debriefing

The MEND ProcessThe MEND Process

The Calling CircleThe Calling Circle

Critical Incident Stress Critical Incident Stress DebriefingDebriefing

Phase1

INTRODUCTION

Phase2

FACTS

Phase3

THOUGHTS Phase

4REACTIO

NS

Introduction PhaseIntroduction Phase

Team members introduce themselvesTeam members introduce themselves

Clarify the goals Clarify the goals

Team leader encourages each member Team leader encourages each member to speak to speak

The team leader reminds the members The team leader reminds the members what is discussed during the meeting what is discussed during the meeting is confidential is confidential

Fact PhaseFact Phase

Extremely brief overview of the critical Extremely brief overview of the critical incident is discussed and the role each incident is discussed and the role each team member participated in during the team member participated in during the critical event critical event

Excessive detail is discouraged Excessive detail is discouraged

Everyone is given an opportunity to Everyone is given an opportunity to speakspeak Decreases anxiety levels among the membersDecreases anxiety levels among the members Shows the group they are in control of the Shows the group they are in control of the

discussion discussion

Thoughts PhaseThoughts Phase

Discuss individuals thoughts about the Discuss individuals thoughts about the critical incidentcritical incident

Important not to discuss the painful Important not to discuss the painful aspects of the event in the beginning aspects of the event in the beginning of this phase of this phase

Reaction PhaseReaction Phase

The heart of Critical Incident Stress The heart of Critical Incident Stress DebriefingDebriefing

Focuses on the impact the stressful Focuses on the impact the stressful event had on the team membersevent had on the team members

Each member is encouraged to discuss Each member is encouraged to discuss their reaction to the eventtheir reaction to the event

Symptom PhaseSymptom Phase

Team members may or may not have Team members may or may not have symptoms related to the stressful symptoms related to the stressful event which occurred event which occurred

The team leader asks the members The team leader asks the members about cognitive, physical, emotional, or about cognitive, physical, emotional, or behavioral symptoms the team behavioral symptoms the team members may be experiencingmembers may be experiencing

Teaching PhaseTeaching Phase

Team leader discusses the symptoms Team leader discusses the symptoms team members may be feeling and team members may be feeling and provides them with explanationsprovides them with explanations

Other topics may be discussed during Other topics may be discussed during this phase if teaching is necessary to this phase if teaching is necessary to help the team membershelp the team members

Re-Entry PhaseRe-Entry Phase

Team members are encourage to ask Team members are encourage to ask any remaining questionsany remaining questions

Final statements or comments are made Final statements or comments are made

The team leader summarizes the The team leader summarizes the meetingmeeting

Final explanations, information, Final explanations, information, guidance, and thoughts are presented to guidance, and thoughts are presented to the groupthe group

The Unexpected Case The Unexpected Case ReviewReview

The MEND ProcessThe MEND Process

Tool for leaders to provide support and Tool for leaders to provide support and resources to their staffresources to their staff

Healthcare providers are our greatest Healthcare providers are our greatest assetasset

Paramount to the success and growth of Paramount to the success and growth of our organizationour organization

Children’s Hospital of Wisconsin in Milwaukee Children’s Hospital of Wisconsin in Milwaukee

MENDMEND

M - M - Meet with the employee 1:1 in a private areaMeet with the employee 1:1 in a private area

E - E - Explore the situation Explore the situation

N - N - Normalize their feelings and response to the Normalize their feelings and response to the event event

D - D - Discuss resourcesDiscuss resources

Children’s Hospital of Wisconsin in MilwaukeeChildren’s Hospital of Wisconsin in Milwaukee

Individual Case ReviewIndividual Case Review

The Calling CircleThe Calling Circle

A circle is participatory in nature, small A circle is participatory in nature, small enough to serve as a workable council, enough to serve as a workable council,

and diverse enough to address whatever and diverse enough to address whatever exists within the reach of its purpose.exists within the reach of its purpose.

C. Baldwin & A. LinneaC. Baldwin & A. Linnea

Three Principles of the Three Principles of the CircleCircle

Leadership is rotatingLeadership is rotating

Responsibility is sharedResponsibility is shared

Reliance is on the spirit of the group: Reliance is on the spirit of the group: Clarified intentionClarified intention Common purpose or highest goalsCommon purpose or highest goals

C. C.

Baldwin & A. LinneaBaldwin & A. Linnea

Three Practices of Three Practices of CouncilCouncil

Attentive listeningAttentive listening

Intentional speakingIntentional speaking

Conscious self-monitoringConscious self-monitoring

C. Baldwin & A. LinneaC. Baldwin & A. Linnea

Shared LeadershipShared Leadership

The Council AgreementsThe Council Agreements:: What is said in the circle belongs to that circleWhat is said in the circle belongs to that circle We listen to each other with discernment, not We listen to each other with discernment, not

judgmentjudgment Each person asks for the support he/she needs Each person asks for the support he/she needs

and offers the support he/she canand offers the support he/she can When the group is uncertain how to proceed, or When the group is uncertain how to proceed, or

in need of a resting point in group process, we in need of a resting point in group process, we will stop action, observe a pause and self reflect will stop action, observe a pause and self reflect

C. Baldwin & A. LinneaC. Baldwin & A. Linnea

The Components of the The Components of the CircleCircle

Start pointStart pointSetting the centerSetting the centerAgreementsAgreementsCheck-inCheck-inThree PrinciplesThree PrinciplesThree PracticesThree PracticesGuardianGuardianCheck-outCheck-out

C. Baldwin & A. LinneaC. Baldwin & A. Linnea

End of Life Case ReviewEnd of Life Case Review

EnvironmentEnvironment

Non-threatening Non-threatening

Contributions provided are seen as Contributions provided are seen as developmental feedback and not as developmental feedback and not as criticism or to blame the individual criticism or to blame the individual

The team seated in a circleThe team seated in a circle

Isolated and quiet spaceIsolated and quiet space

FeedbackFeedback

Most crucial element of learningMost crucial element of learning

Leaders must be specific, objective, Leaders must be specific, objective, and honest when identifying indicators and honest when identifying indicators of performance of performance

Feedback can be Feedback can be Individually focused or Individually focused or Team focused Team focused

Team FeedbackTeam Feedback

Situation assessmentSituation assessment

Supporting behaviorSupporting behavior

CommunicationCommunication

Leadership or initiativeLeadership or initiative

Facilitators & LeadersFacilitators & Leaders

Guide the team in the self-corrective Guide the team in the self-corrective process byprocess by Providing positive and negative examples Providing positive and negative examples

of each teamwork componentof each teamwork component Provide actual and potential impacts of Provide actual and potential impacts of

these behaviors on performance outcomesthese behaviors on performance outcomes Provide solutions to each problem Provide solutions to each problem

identified identified

Do NOT…Do NOT…

Fail to protect or block members from Fail to protect or block members from harmful disclosuresharmful disclosures

Force active participation before a Force active participation before a team member is ready to do so. team member is ready to do so.

Encourage confrontation and Encourage confrontation and expression of anger from team expression of anger from team membersmembers

Pressure members to accept unwanted Pressure members to accept unwanted feedback or demands for changefeedback or demands for change

The Role of Facilitator & The Role of Facilitator & LeaderLeader

Understand the principles of group Understand the principles of group dynamicsdynamics

CareCare

Manage ethical issuesManage ethical issues

Build cohesion among the team Build cohesion among the team membersmembers

“Only when nurses take time to heal themselves can they truly be available to aid in the healing of

others.”

Bush, 2009

ReferencesReferences Bush, N.J. (2009). Compassion fatigue: Are you at risk. Bush, N.J. (2009). Compassion fatigue: Are you at risk. Oncology Oncology

Nursing Forum Nursing Forum 36(1), 24-28.36(1), 24-28.

Mitchell, J.T. Critical incident stress debriefing. Mitchell, J.T. Critical incident stress debriefing. Trauma. Trauma. Retrieved Retrieved from from www.infor-trauma.org

Nachshoni, T., Knobler, C.H.Y., Jaffe, E., Peretz, M.G., & Yehuda, Y.B. Nachshoni, T., Knobler, C.H.Y., Jaffe, E., Peretz, M.G., & Yehuda, Y.B. (2007). Psychological guidelines for a medical team debriefing after (2007). Psychological guidelines for a medical team debriefing after a stressful event. a stressful event. Military Medicine, 172,Military Medicine, 172, 581-585. 581-585.

Pender, D.A., & Prichard, K.K. (2009). ASGW best practice guidelines Pender, D.A., & Prichard, K.K. (2009). ASGW best practice guidelines as a research tool: a comprehensive examination of the critical as a research tool: a comprehensive examination of the critical incident stress debriefing. incident stress debriefing. The Journal for Specialists in Group Work, The Journal for Specialists in Group Work, 3434(2), 175-192. (2), 175-192.

Salas, E., Klein, C., King, H., Salisbury, M., Augenstein, J.S., Birnbach, Salas, E., Klein, C., King, H., Salisbury, M., Augenstein, J.S., Birnbach, D.J., . . . Upshaw, C. (2008). Debriefing medical teams: 12 evidence-D.J., . . . Upshaw, C. (2008). Debriefing medical teams: 12 evidence-based best practices and tips. based best practices and tips. Joint Commission on Accreditation of Joint Commission on Accreditation of Healthcare Organization, 34Healthcare Organization, 34(9), 518-527(9), 518-527

Tamm, W. J. & Luyet, J. R. (2004). Radical Collaboration. New York: HarperCollins Publishers.