Team debriefings in healthcare: aligning intention and impactBMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n2042 (Published 13 September 2021) Cite this as: BMJ 2021;374:n2042
- Michaela Kolbe, director, Simulation Centre1 2,
- Sven Schmutz, director of cardio psychology,
- Julia Carolin Seelandt, head of training and faculty development1,
- Walter J Eppich, chair4,
- Jan B Schmutz, senior researcher and lecturer2
- 1University Hospital Zurich, Simulation Centre, Switzerland
- 2ETH Zurich, Switzerland
- 3University Hospital Bern, Inselspital, Switzerland
- 4RCSI University of Medicine and Health Sciences, RCSI SIM Centre for Simulation Education and Research, Ireland
- Correspondence to M Kolbe
What you need to know
Learning-oriented debriefings support patient care by helping teams learn and improve
Team debriefing with the aim of preventing post-traumatic stress disorder (PTSD) is not recommended. Do not conflate debriefing intentions to promote learning with intentions to treat acute stress disorder (ASD), PTSD, or anxiety and depressive symptoms
Support team members with potential symptoms of ASD, PTSD, anxiety, or depressive disorder to access specific therapeutic interventions guided by trained professionals
If leading a team debriefing, carefully reflect beforehand on debriefing intentions and pay close attention to signs of participant distress. If participants show signs of distress during a team debriefing switch intention from learning to managing by listening, acknowledging, and normalising reactions without pressing for details
The covid-19 pandemic has renewed focus on debriefings to improve performance among healthcare providers: debriefings help teams learn quickly and manage patients more safely.1234 However, in some circumstances, debriefings may harm more than help. In this article we introduce debriefing and its benefits, highlight the potential consequences when debriefing intentions blur, and offer guidance to navigate shifting debriefing objectives, for example during instances of clinicians’ distress related to patient care.
What are team debriefings?
Team debriefings (also known as after action reviews) are guided meetings during which members discuss, interpret, and learn from recent events.56 Debriefings will typically include both retrospective (eg, collaborative sense making in information-rich and ambiguous environments) and prospective reflection (eg, sustaining positive performance, planning treatments, anticipating problems).57 They foster reflection on clinical practice for the individual and the team. Various debriefing tools and structures are in use, such as TALK (Target, Analysis, Learning, Key Actions),8 PEARLS (Promoting Excellence and Reflective Learning in Simulation),9 and REFLECT (Review the event, Encourage team participation, Focused feedback, Listen to each other, Emphasise key points, Communicate clearly, Transform the future).910 A typical structure might be: (a) setting the scene, (b) sharing initial reactions, (c) collecting and analysing perceptions, feedback, and interactions, (d) specifying take-home messages.34910111213141516 Organisations with high levels of risk and hazard such as aviation, military, and hospitals use debriefings as a safety management tool.17 Implementation of debriefings varies across contexts within larger systems of interventions. In healthcare, debriefings usually occur within educational contexts or after clinical events that involve high acuity, novelty, uncertainty, stress, or complexity (box 1).20 Debriefings may immediately follow events or take place hours or days later.5
A paediatric critical care unit starts holding interdisciplinary debriefings several days after cardiac arrest events, to review key resuscitation metrics18
Several hospitals start holding debriefings after patient falls, to learn and prevent further falls19
During covid-19, an emergency department implements remote, 10 minute, structured, end-of-shift debriefings to encourage reflection and team learning4
Group based interventions such as Balint groups and Schwartz Center Rounds highlight relationships and communication with patients and among peers2122; however, team debriefings focus explicitly on improving teamwork by
Aligning with organisational safety culture and other support systems, occurring regularly and, ideally, preceded by briefings.9 15 17 24 35 36
Debriefing to learn versus debriefing to treat
The purpose of team debriefing, as stated in the medical education and organisational science literature, is to learn from clinical events.2568111416 By contrast, in clinical psychology “debriefing” has been studied as an intervention to reduce psychological morbidity, such as acute stress disorder (ASD) and post-traumatic stress disorder (PTSD), after experiencing traumatic events (fig 1A).33 More simply, debriefing goals are discipline-specific and shaped by intended outcome: an intention to learn (debriefing-to-learn)20 or an intention to treat (debriefing-to-treat).35
Teams that regularly debrief to learn perform better than those who do not. Two meta-analyses investigated the performance implications of learning-oriented debriefings, and both reported improvements in measures of performance.1531364546 In combination with briefings, debriefings are associated with an increase in the number of quality improvement strategies used, shorter durations of surgery, improved coordination between team members, and reduced number of adverse events in operating theatres and labour and delivery wards.234748 Debriefings-to-learn shift information processing from automatic to conscious activities, promote understanding about relationships between teamwork and taskwork, and create a shared understanding among team members.1127293149
By contrast, debriefing-to-treat does not prevent PTSD and other psychological repercussions of a traumatic event (eg, anxiety or depressive symptoms) and may be harmful for some.35 The World Health Organization recommends that psychological debriefings should not be used for people exposed recently to a traumatic event as an intervention to reduce the risk of post-traumatic stress, anxiety, or depressive symptoms. This recommendation is classified as strong.35 The corresponding quality of evidence is graded as low with regard to PTSD symptoms, very low with regard to anxiety and depressive symptoms, and very low for a small effect favouring control over psychological debriefing on preventing PTSD and depression at follow-up.33373839 The balance of benefits versus harms is not favourable.35 In sum, whereas debriefings-to-learn promote better performance,3136 debriefings-to-treat do not prevent psychological repercussions of a traumatic event and may be harmful.32333440414243 Being aware of the distinction between debriefing-to-learn and debriefing-to-treat is therefore important for anyone who is facilitating debriefing sessions (box 2).
Why understanding the purpose of the debrief matters
Debriefings-to-learn foster sense making thorough examination of mental frames as drivers of human behaviour,11 requiring respectful persistence by facilitators to explore uncomfortable topics such as medical error or hierarchy.51150 However, this mindful persistence, even if respectful, is contraindicated when participants are distressed (fig 1B) and facilitators are not trained to treat strong emotional reactions, particularly in group settings.51 Especially when distressed, people need respect for their boundaries, speaking about their distress only when they choose.51 Particularly now, clinicians treating critically ill patients with covid-19 may experience prolonged, extreme situations that may trigger both acute and post-traumatic stress and require psychological support.525354 Participant distress may prompt facilitators—typically trained to moderate debriefings-to-learn but not manage psychological trauma—to switch their intention from learning to prevention and treatment. Although this intention switch likely arises from a genuine desire to help and a belief that “talking about it brings relief,” evidence suggests that psychological debriefing may not prevent ASD, PTSD, anxiety, or depressive symptoms and has the potential to cause harm.32333440414243
Several psychological mechanisms explain why these harmful effects may occur:
Unwanted, detailed group discussion may trigger intense imagined re-exposure to traumatic events which serve as further trauma, exacerbating symptoms without the necessary assistance to process intense emotions.3355 Principles of psychological first aid may be violated (eg, don’t encourage individuals to talk about or relive traumatic events)51
By focusing on psychological distress, facilitators may create expectations of future psychological symptoms and may, paradoxically, enhance distress that likely would dissipate without intervention5657
Uniform group debriefing approaches may neglect individual preferences and interfere with individual adaptive processes. Paradoxically, in instances of high participant distress, just “talking” and reflecting on emotions may miss the mark and not influence the underlying psychological processes positively395558
Some critical voices in medical education question the trend to view talking as emotional regulation and advocate against widespread adoption of debriefing practices and peer support without clear alignment between process and intended outcomes.59RETURN TO TEXT
Practical considerations for debriefing facilitators
We base these practical considerations on our knowledge of the literature and our combined experience as clinicians, crisis and team psychologists, and healthcare educators who have been regularly debriefing in both clinical and simulated learning environments for more than a decade. Requests for clinical debriefings after particularly stressful non-routine events typically stem from various sources, including unit physicians or nursing leadership or distressed team members. When we receive a request for a team debrief, the first step is to decide whether to debrief, and, if so, how. We believe that to minimise harm from ineffective debriefings, health professionals require criteria about how and when, and when not to debrief.537506061
Clarify who requests debriefing, why, and for what events. Are expectations mismatched?62
Analyse risks (eg, re-exposure to traumatic event) and benefits (eg, opportunity to learn as a team)
Seek help in deciding whether to proceed and how to co-facilitate
Anticipate signs of potential distress (fig 1B) and how you will manage it
Reflect on boundary conditions: What support is available from my organisation to offer alternative help if team members show signs of distress? What prior experience with mutual reflection may team members have made?
When we receive requests to facilitate debriefing, we consider the intention or purpose of the debrief: if it is for learning and improvement, we recommend conducting debriefings-to-learn (fig 1B). If the request is to prevent or treat distress or if we anticipate strong emotional reactions and psychological distress, neither a debriefing-to-learn nor debriefing-to-treat approach is indicated. However, we recognise that in these circumstances a team may value coming together to understand what happened, promote a sense of control, and support one another.354062 Here, we propose an alternative intention: debrief-to-manage. Debriefing-to-manage provides low-key opportunities to acknowledge and normalise reactions, to share experiences, and to identify needs for further support—without asking participants to explore in detail what happened (box 3).6265 In addition, we recommend ensuring that all team members have access to mental health professionals in case of symptoms of possible ASD, PTSD, or other mental health disorders.323334
Strategies for debriefing to manage, where participants are distressed and/or debriefing intentions are unclear
State explicitly at the outset that each participant may decide which topics they listen to and discuss (“Please feel free to participate in a way that is right for you, whether just listening, sharing your perspective if you wish, or indicating if you need a break”)
Emphasise that participation is voluntary, and offer the option to leave at any time
The facilitator’s role when debriefing-to-manage is more passive then when debriefing-to- learn: speaking less, pausing and listening more
Respect participants’ individual preferences, never force participation or mandate topics
Provide space for questions (“What questions do you have about what you just experienced?”)
Acknowledge, normalise, and validate
Normalise the variability of acute symptoms of distress and emotional reactions (“These are normal reactions to such incidents”)
Be empathic and respectful (“Thank you for sharing your thoughts with us”)
Emphasise that these reactions are understandable
Do not encourage participants to supress emotions
Respect objectives and boundaries
Stimulate only superficial cognitive processing—no in-depth inquiry about specific aspects about what people did or did not do during the event
Avoid persistently requesting that participants share a perspective, or repeatedly inviting comments from specific participants who may prefer to listen only63
Do not explore potentially traumatic events in detail due to risk of re-traumatisation62
Provide information about available support and treatment services if overwhelming levels of distress arise (eg, NHS Practitioner Health Programme in the UK)64
Reiterate a low threshold for future questions and concerns (eg, “What else?”)
Offer your availability after the debriefing for further questions
Practical strategies for starting both debriefing-to-learn and debriefing-to-manage include
Contribute to psychological safety (perception that it is safe to take interpersonal risks) by clarifying expectations (ie, offer explicit ground rules and goals; make debriefing objectives of different stakeholders transparent and foster shared agreement), commit to confidentiality, avoid imposing rigid objectives, invite and appreciate input, hold participants in high regard, and be inclusive61
Monitor the debriefing process: are you guiding a learning process or beginning to treat symptoms?
If participants show signs of distress or if the initial debriefing request was vague, deliberately switch intention from learning to managing.
Education into practice
What are your experiences as the participant or facilitator of a debriefing? Was the purpose of the debriefing clear to you?
During the covid-19 pandemic, how has your organisation approached team debriefings?
How patients were involved in the creation of this article
A senior intensive care nurse who initiated and conducted team debriefings in temporary covid-19 intensive care units, an experienced anaesthesia nurse and debriefer, and a patient who recovered from severe covid-19 read the manuscript. All provided valuable feedback that strengthened the paper. For example, we highlighted the importance of team debriefings and developed a clearer explanation of the fine line between different debriefing intentions (ie, prevention and treatment versus learning).
How this article was created
Two distinct lines of inquiry inform debriefing practice: research on team debriefings91123262728293031 and psychological debriefings.323334 We grounded this review in our debriefing experiences and published empiric and conceptual papers, meta-analyses, and reviews identified through systematic search of PubMed databases up to 30 May 2021 and Google scholar with terms “debriefing,” “distress,” “group,” and “team.”
Conflicts of Interest: We have read and understood the BMJ policy on declaration of interests. Michaela Kolbe, Jan Schmutz and Walter Eppich are faculty for The Debriefing Academy, which runs debriefing courses for healthcare professionals. Michaela Kolbe and Julia Seelandt are faculty at University Hospital Zurich Simulation Centre and train educators in debriefing. Walter Eppich and Jan Schmutz receive honorariums from PAEDSIM e.V. to teach simulation educator courses.
Provenance and peer review: commissioned, based on an idea from the authors.