The Use of Debriefings for Caregiver Stress

1. The Use of Debriefings for Caregiver Stress Marcie Peterson, MSN, RN, CCRN, CNML Children’s Hospital & Medical Center April 16th, 2012

2. Have you ever… • Struggled with leaving work at work • Performed a clinical assessment • Lost a patient • Become too attached • Felt like you were doing more harm than good

3. As Nurses… • Repeated exposure • Hear the stories by those we help • We absorb other people’s losses • Comfort our patients & families in need

4. “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

5. How does all of this affect us? • Work Environment • Team • Experience level • Relationships • Spiritually

6. How do we COPE???

7. Debriefing • A conference or discussion held with the team after an intense event or catastrophe; all aspects of the event are discussed and analyzed • A process where support is given to groups or individuals who have experienced an extraordinary clinical event that has the potential to cause unusually strong emotional reactions

8. History • Developed by Jeffrey T. Mitchell in 1974 • First used with small groups of paramedics, firefighters, and law enforcement officers • Over time, debriefings spread to the military services, airlines, railroads, and hospitals

9. The Importance of Debriefings • Patient Safety • Clear thinking is essential for overcoming the chaotic and stressful environment in which patient care teams operate • Shared Understanding • Has developed during debriefings to improve team performance • Gained Insight • Use knowledge from past experience to improve future performance

10. The Importance of Debriefings • Guilt • Individual team members may feel responsible for the event • Coping Skills • Teams learn practical applications to assist in dealing with difficult situations in the future • Communication • Teams can develop new communication methods or strategies to use during subsequent events.

11. 12 Evidence-Based Best Practices • Must be diagnostic • Create a supporting learning environment • Encourage team to be attentive of teamwork process during performance • Educate Facilitators/Leaders on the Art & Science of leading debriefings • Team members feel comfortable • Focus on a few critical performance issues Joint Commission Journal on Quality and Patient Safety, 2008

12. 12 Evidence-Based Best Practices • Describe specific teamwork interactions & processes • Support feedback with objective indicators of performance • Provide outcome feedback later and less frequently than process feedback • Provide both individual & team-oriented feedback • Shorten the delay between task performance and feedback • Record conclusions made and goals set Joint Commission Journal on Quality and Patient Safety, 2008

13. Goals to Conduct a Debriefing • Identify the nature of the problem • Review why…how…and what resulted • Allow team members to discuss • The decisions made during the event • What could have been done differently • Miscommunication • Unprofessional behavior • The need for remediation or training • Identify success and the positives which came out of the event

14. Timing • Timing is ESSENTIAL!!! • Should occur shortly after the incident • Within 24 to 72 hours

15. Tools Used for Debriefings • Critical Incident Stress Debriefing • The MEND Process • The Calling Circle

16. Critical Incident Stress Debriefing Phase 1 INTRODUCTION Phase 2 FACTS Phase 3 THOUGHTS Phase 4 REACTIONS Phase 6 TEACHING Phase 7 RE-ENTRY Phase 5 SYMPTOMS

17. Introduction Phase • Team members introduce themselves • Clarify the goals • Team leader encourages each member to speak • The team leader reminds the members what is discussed during the meeting is confidential

18. Fact Phase • Extremely brief overview of the critical incident is discussed and the role each team member participated in during the critical event • Excessive detail is discouraged • Everyone is given an opportunity to speak • Decreases anxiety levels among the members • Shows the group they are in control of the discussion

19. Thoughts Phase • Discuss individuals thoughts about the critical incident • Important not to discuss the painful aspects of the event in the beginning of this phase

20. Reaction Phase • The heart of Critical Incident Stress Debriefing • Focuses on the impact the stressful event had on the team members • Each member is encouraged to discuss their reaction to the event

21. Symptom Phase • Team members may or may not have symptoms related to the stressful event which occurred • The team leader asks the members about cognitive, physical, emotional, or behavioral symptoms the team members may be experiencing

22. Teaching Phase • Team leader discusses the symptoms team members may be feeling and provides them with explanations • Other topics may be discussed during this phase if teaching is necessary to help the team members

23. Re-Entry Phase • Team members are encourage to ask any remaining questions • Final statements or comments are made • The team leader summarizes the meeting • Final explanations, information, guidance, and thoughts are presented to the group

24. The Unexpected Case Review

25. The MEND Process • Tool for leaders to provide support and resources to their staff • Healthcare providers are our greatest asset • Paramount to the success and growth of our organization Children’s Hospital of Wisconsin in Milwaukee

26. MEND • M - Meet with the employee 1:1 in a private area • E - Explore the situation • N - Normalize their feelings and response to the event • D - Discuss resources Children’s Hospital of Wisconsin in Milwaukee

27. Individual Case Review

28. The Calling Circle A circle is participatory in nature, small enough to serve as a workable council, and diverse enough to address whatever exists within the reach of its purpose. C. Baldwin & A. Linnea

29. Three Principles of the Circle • Leadership is rotating • Responsibility is shared • Reliance is on the spirit of the group: • Clarified intention • Common purpose or highest goals C. Baldwin & A. Linnea

30. Three Practices of Council • Attentive listening • Intentional speaking • Conscious self-monitoring C. Baldwin & A. Linnea

31. Shared Leadership • The Council Agreements: • What is said in the circle belongs to that circle • We listen to each other with discernment, not judgment • Each person asks for the support he/she needs and offers the support he/she can • When the group is uncertain how to proceed, or in need of a resting point in group process, we will stop action, observe a pause and self reflect C. Baldwin & A. Linnea

32. The Components of the Circle • Start point • Setting the center • Agreements • Check-in • Three Principles • Three Practices • Guardian • Check-out C. Baldwin & A. Linnea

33. End of Life Case Review

34. Environment • Non-threatening • Contributions provided are seen as developmental feedback and not as criticism or to blame the individual • The team seated in a circle • Isolated and quiet space

35. Feedback • Most crucial element of learning • Leaders must be specific, objective, and honest when identifying indicators of performance • Feedback can be • Individually focused or • Team focused

36. Team Feedback • Situation assessment • Supporting behavior • Communication • Leadership or initiative

37. Facilitators & Leaders • Guide the team in the self-corrective process by • Providing positive and negative examples of each teamwork component • Provide actual and potential impacts of these behaviors on performance outcomes • Provide solutions to each problem identified

38. Do NOT… • Fail to protect or block members from harmful disclosures • Force active participation before a team member is ready to do so. • Encourage confrontation and expression of anger from team members • Pressure members to accept unwanted feedback or demands for change

39. The Role of Facilitator & Leader • Understand the principles of group dynamics • Care • Manage ethical issues • Build cohesion among the team members

40. “Only when nurses take time to heal themselves can they truly be available to aid in the healing of others.” • Bush, 2009

41. References • Bush, N.J. (2009). Compassion fatigue: Are you at risk. Oncology Nursing Forum 36(1), 24-28. • Mitchell, J.T. Critical incident stress debriefing. Trauma. Retrieved from www.infor-trauma.org • Nachshoni, T., Knobler, C.H.Y., Jaffe, E., Peretz, M.G., & Yehuda, Y.B. (2007). Psychological guidelines for a medical team debriefing after a stressful event. Military Medicine, 172, 581-585. • Pender, D.A., & Prichard, K.K. (2009). ASGW best practice guidelines as a research tool: a comprehensive examination of the critical incident stress debriefing. The Journal for Specialists in Group Work, 34(2), 175-192. • Salas, E., Klein, C., King, H., Salisbury, M., Augenstein, J.S., Birnbach, D.J., . . . Upshaw, C. (2008). Debriefing medical teams: 12 evidence-based best practices and tips. Joint Commission on Accreditation of Healthcare Organization, 34(9), 518-527 • Tamm, W. J. & Luyet, J. R. (2004). Radical Collaboration. New York: HarperCollins Publishers.