Solving the mystery of transitioning from simulation debriefing to clinical event debriefing.
By Una Harrington & Melanie Rule
As Emergency physicians we need frequent exposure to critically unwell patients in order to hone our resuscitation skills. It is often said that the mark of a good critical care clinician is one who runs towards the sickest patients.
However, repeated exposure to these events can take a toll on the staff involved. Many find themselves emotionally affected by what they see and experience. Particular events such as the death of a child, grossly disfiguring trauma, resuscitating a staff member or an unanticipated poor outcome can leave staff experiencing strong emotional reactions to these events.
If staff members do not receive the right support in the aftermath of these events, there is a risk of them suffering long-term impairment and also becoming second victims (1) There is also a growing awareness of the impact of repeated exposure to these events over the course of a career and the effect this can have on the clinician in terms of their own psychological health. In response to these risks, there is growing demand for debriefing of staff in the clinical environment following critical events.
Many health professionals, like us, are simulation educators who have been trained in debriefing as part of our simulation training. Increasingly, we are finding ourselves being the ones asked to facilitate debriefing of our colleagues in the work environment, outside of the sim room. This comes with a feeling of discomfort for most educators, as we are acutely aware that we have been trained for simulation event debriefing NOT clinical event debriefing. The assumption is made that the skills required are the same, or perhaps we are just seen as the best available option in the absence of staff with formal training in clinical event debriefing.
So, we find ourselves pondering the following questions:
- Is simulation debriefing a useful skillset that can help us to provide clinical event debriefing?
- Are there significant differences in debriefing staff after a real event?
- Where can one get specific training in clinical event debriefing?
As an attempt to answer these questions, Una & Melanie from WRaP EM attended the highly sought-after Clinical Event Debriefing workshop at the DFTB18 conference.
This workshop was hosted by some very high-profile names, Prof. Victoria Brazil (Emergency Physician & Simulation Educator), Dr. Ian Summers (Emergency Physician & Simulation Educator), Dr. Ben Symon (Paediatric Emergency Physician & Simulation Educator) and Liz Crowe (Senior Social worker & experienced clinical debriefer). If you are interested in more gold from Victoria Brazil and Ben Symon – just head over to simulcast.
What struck us on the day was a number of things:
- This was a very popular workshop & clearly met an unmet need for many people given it was booked out months ahead of schedule.
- There is a very broad range of experience across those who are now getting involved in both simulation and clinical debriefing.
- There is a certain mystery as to what is the best way to transition one’s practice from the simulation debrief to the clinical debriefing setting.
What follows are our reflections on some of the key points discussed in the workshop. We hope to help shed some light on the key differences between simulation debriefing & clinical event debriefing.
We both understand that it feels like we need to be a cross between Hercule Poirot and Sherlock Holmes to get to the bottom of this mystery!
Mystery 1
Simulation and Clinical Debriefing – Same-same but different?
How are they similar?
Ben Symon succinctly outlined what the Simulation debrief and Clinical debrief have in common with ‘The three D’s’.
D –Deactivation
- Moving staff from an ‘activated’ emotional state to a calmer, ‘deactivated’ state
D –Deconstruction
- Analysing the case and the groups performance, and considering options for optimisation in future similar cases
D –Dissemination
- Sharing a mental model about the case (hot debrief), and later sharing the outcomes for the patient, and any systemic process changes (cold debrief)
But how are they different?
- Simulation debriefing
- Generally, occurs directly after the simulation
- Learners are protected from direct clinical duties
- Scene is set beforehand including discussion of psychological safety & ground rules during a pre-brief
- The patient is not real!
- Second chances are possible if you get it wrong.
- So the emotional load may be slightly lower.
- Clinical debriefing
- Hot debriefing usually happens shortly after the clinical event.
- Cold debriefing may occur some time later, generally 1-2 weeks after the clinical event.
- Participants generally have a clinical load at the time so are likely to feel competing interests for their time.
- The patient is real – so the emotional load is likely to be greater.
Mystery 2
Let’s talk about the lingo
The terminology used to describe the clinical event debriefing is somewhat foreign to us simulation trained debriefers.
In clinical event debriefing, we talk about the:
Hot debrief vs Cold debrief
- which refers solely to the timing of the event
Emotional Versus Operational debrief
- which refers more to the aim of the event
Mystery 3
The devil is in the details
When we unpack the details of both simulation & clinical event debriefing there are yet more similarities and differences.
Why?
| Simulation Debrief | Clinical Event Debrief |
| Provide emotional deactivation to allow participants to focus on learning outcomes.
To highlight key learning points. To correct learner errors in knowledge or clinical reasoning. To focus on non-technical skills such as team performance, communication & leadership. To support the learner.
|
Hot debrief –
Provide emotional deactivation to allow staff to return to clinical duties To highlight urgent & significant quality and safety issues. To provide emotional support to staff & identify staff needing additional support. Cold Debrief – Explore impact of non-technical skills such as team performance, communication & leadership. To provide ongoing emotional support to staff & normalise the emotional response to the event. To provide updates & closure regarding the patient outcome. To identify staff needing further emotional support outside the debrief setting |
When?
| Simulation Debrief | Clinical Event Debrief |
| Immediately after the simulation event is completed
|
Hot debrief – Immediately after the clinical event has concluded (or at least on same shift)
Cold debrief – 1-2 weeks after clinical event has concluded |
Who?
| Simulation Debrief | Clinical Event Debrief |
| Facilitator – Simulation educator
Participants – learners |
Hot Debrief
Facilitator – Senior medical or nursing staff member who may or may not have been involved in the clinical event Participants – all team members Cold Debrief Facilitator – Trained person from senior medical or nursing or external provider Participants – voluntary, open to any staff member directly involved in event |
Where?
| Simulation Debrief | Clinical Event Debrief |
| Private room co-located in non-clinical simulation centre
Clinical area if in-situ simulation
|
Hot debrief – resuscitation bay in clinical area or nearby private area
Cold debrief – Private room in non-clinical area |
Have we solved the case?
Whilst there are some similarities between a simulation debrief and a clinical event debrief, they are very different concepts which serve very different purposes.
Departments should not just rely on skills obtained for the purposes of simulation to fill a need for clinical event debriefing in the workplace.
This is an ongoing area of interest for us at WRaP EM so watch this space for our full module on Debriefing that will be completed in late 2018. We hope this will provide more detail on all of the above concepts for those wishing to take a deeper dive into the topic.
In the meantime, we would encourage you all to start the conversation about what clinical event debriefing may look like in your department.
Perhaps, start by agreeing on what triggers a debriefing event, and whose responsibility it is to run it. This is important so that it is not just left up to the simulation educators in your department to solve the mystery.
References
- Medical Error: The Second Victim. Albert Wu. BMJ 2000;320:726
WRaP EM 
I believe that sim facilitators could be great mentors for unit educators /charge nurses / medical leads to run clinical debriefings but should not be the ones responsible for the clinical debriefing. Sim educators may not understand the context or culture of the unit therefore leading to increasing frustrations for the staff. I think sim educators should mentor but not conduct actual hot or cold unit clinical debriefings. That should be someone who was involved in he case or know the staff and department well and can help provide follow up on issues brought up such as LST or interdiciplinary communication issues.
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