Simulcast Journal Club April 2019


Introduction :  

Simulcast Journal Club is a monthly series that aims to encourage simulation educators to explore and learn from publications on Healthcare Simulation Education.  Each month we publish a case and link a paper with associated questions for discussion.  Inspired by the ALiEM MEdIC series, we moderate and summarise the discussion at the end of the month, including exploring the opinions of experts from the field. 

The journal club relies heavily on your participation and comments and while it can be confronting to post your opinions on an article online, we hope we can generate a sense of “online psychological safety” enough to empower you to post!  Your thoughts are highly valued and appreciated, however in depth or whatever your level of experience.  We look forward to hearing from you. 

Journal Club (5)

Title :  “How to get away with debriefing a murder 

Nitin liked to think that he had a strong growth mindset.  He enjoyed unexpected challenges and tried to extract a valuable learning point from any kind of problem.  But truth be told when he had received the formal invitation to start working at the sim centre, he hadn’t expected to eventually learn that moving a real dead body was significantly harder than moving a Sim Man 3G back to the supply room.  It was more slippery for one thing. 

“So let me get this straight…” puffed his colleague Brad as they struggled with the weight.  “We’re moving Snythe’s body into the supply room, tampering with the crime scene and potentially incriminating ourselves, all so that we can debrief his death in our standard debriefing room?”. 

“The roads are flooded, Brad.  We could be stuck here for hours.  Everyone is stressed and we need a safe place to talk.  And safe spaces don’t usually feature the corpses of murdered intensivists.” Said Nitin. 

“Are you sure debriefing this is a good idea?” asked Brad, “I thought debriefing clinical events is associated with increased PTSD score?.”. 

Nitin placed Snythe’s shoulders on the floor for a moment.  “You mean the Cochrane review from ages ago? It didn’t seem that relevant to our population.  And besides, Nimali is trying to look after our team.  I’m not sure we need an evidence base to connect emotionally and support each other”. 

Brad frowned.  “I’m serious Nitin, what if talking about this stuff in the wrong way makes the whole situation worse?  We’re all at serious risk of PTSD from this.”.  Together they picked up the body again and shuffled towards the supply room. 

Nitin shuddered as he felt Snythe’s cold hand drop out of position and onto his back.  Something was… dripping on his shirt.  An optimistic growth mindset was one thing, but if he was honest with himself, he’d had  significantly better days.  “To be fair Brad, I’m not sure it’s the conversation afterwards that causes the complex psychological trauma. 

He looked piercingly at Brad for a moment and scowled.  “Besides.  We both know why you’re really worried.”. 

The Article 

Hollingsworth, C., Wesley, C., Huckridge, J., Finn, G. and Griksaitis, M. (2017). Impact of child death on paediatric trainees. Archives of Disease in Childhood, 103(1), pp.14-18. 

Discussion :  

As Clinical Event Debriefing gains traction in hospitals around the globe, some clinicians are warning us about the potential harms from having learning conversations in the context of patient death.  In their article from 2017, Hollingsworth et al explore the psychological impact of child death on paediatric trainees, but in doing so come to the conclusion that Attending a debrief following child death may be associated with symptoms of ASR/PTSD. 

What are your thoughts about this article, it’s methods and its’ conclusions? 

References : 

Hollingsworth, C., Wesley, C., Huckridge, J., Finn, G. and Griksaitis, M. (2017). Impact of child death on paediatric trainees. Archives of Disease in Childhood, 103(1), pp.14-18. 

 

 


About Ben Symon

Ben is a Paediatric Emergency Physician at The Prince Charles Hospital in Brisbane and a Simulation Educator at Lady Cilento Children's Hospital. He currently teaches on a variety of paediatric simulation based courses on paediatric resuscitation, trauma and CRM principles. Ben has a growing interest in encouraging clinical educators to be more familiar with simulation research.


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20 thoughts on “Simulcast Journal Club April 2019

  • FARRUKH JAFRI

    Selection bias from the survey design aside (although they did get a 50% response rate which is fantastic), even in our own programs studying clinical event debriefing, there does tends to be a bias regarding which cases are debriefed (usually the resuscitations). Were the cases debriefed as opposed to those that were not debriefed more unexpected? More traumatic? Prone to medical error? Unfortunately, this is something we just won’t know.

    Certain numbers were concerning to me such as 17% of the students feeling unsupported following the death of a child or how 9% had symptoms to meet criteria for ASR and an additional 5% for PTSD after 1 month. I also liked that they added a question on exercise. While ASR and PTSD appeared less prevalent in those who exercise daily (p value 0.088) and we should continue to encourage physical well being, it was not significant and it was still a big number (8% with a small n). I do get annoyed when the answer to burnout and moral injury is to do yoga classes or have food services delivered to your door. It does not address the vast undercurrent of problems that our staff have to manage.

    Ultimately, through a debrief, we are looking for candid, honest appraisal for continued process and team improvement (at least that is how I interpret it). I feel that we should have a pause regarding whether this is something that should be debriefed. One of our prompts on whether we should debrief a case is if there is a potential for a second victim or a psychologically traumatic event. Our core staff of debriefers has been trained as opposed to what appears to be mostly untrained debriefers in the study. However, we do stay clear of cases that can be potentially traumatizing. I don’t have a great answer for this, but I do worry that we can worsen the risk of a second victim.

    I find these cases tend to be debriefed after no matter what, often informally. As the study demonstrated, people talk to peers, spouses, etc. In the moment, what I feel may be important will be to name the dynamic if there is concern for a potential second victim. “Guys, that was a really tough case. Talking about it now may not be the right time but I do want to check in on everyone and perhaps we can have an organized talk in the next few days after we have some time to reflect. Please come up to me and let’s talk privately if you need to.” In the past, we have organized sessions with our hospital therapist with open hours after potentially psychologically traumatic cases. The problem with this is that they are often only available during business hours and this excludes staff working evenings and nights.

    • Ben Symon Post author

      Hi Farrukh, thanks so much for such a thoughtful and detailed response. I think you’ve raised a number of great points.
      One that particularly resonates with me is the point that these cases are always debriefed. It’s just that if we don’t implement a structure, then it occurs in the tea room or at a bar. That isn’t necessarily a bad thing I guess, since people will often self select the way they want to process something, but it puts the isolated or overwhelmed at risk of being left on their own.

      For myself I think it’s important to differentiate between PTSD scoring and actually having PTSD, which I think is a very different thing. Is it possible having an honest conversation allowed people to acknowledge distress rather than hiding it? Maybe that’s my own confirmation bias calling…

      With regards to your comments about wellness being about yoga and food deliveries, I agree that while those things can be nice, it can often be a bandaid over a deeper problem. For me wellness is about processing the complex emotions and experiences we face in our workplace, and that means acknowledging that they happened and ’emotionally digesting’ what has happened and what our response to it is. I think that’s the only true path to maintaining psychological health in an intense critical care environment.

  • Paul Elliott

    I think that this article is more about the ability for pediatric trainees to cope with the unexpected death of a child and its link to PTSD rather than the link to debriefing. I am always a bit cautious of studies which make links like this; Is it really a causation (increased prevalence of ….PTSD if they had attended a debrief) or just a correlation? Is it also dependent on what is discussed in the debrief? From my own experience having more information about the case and someone else making the links for me has been what I have found beneficial in understanding why a patient has died. This has often occurred in the form of a debrief, the ‘we want to understand what happened and why, support each other, and see what we can change for next time’. I think with the pediatric trainees is there also a factor of being judged by families during/post event?, this may also explain the ‘feelings of guilt’ mentioned in the article.

    I think stress management and coping techniques are a very individual process and it is not always possible to cover these topics to the depth that is sometimes required in basic training. What works for one person, might not next time and might not for someone else. Many health services now employ Employee Assistance Programs (EAP) as part of their staff well being programs, however how effective these services are to health professionals dealing with very specific and stressful situations on a daily basis I do not know.

    • Ben Symon Post author

      Hi Paul, thanks so much for coming along, it’s great to have you here again.
      I think your comments regarding the potential link between association and causation as a bit of a stretch, and I also agree this article is more about psychological recovery post unexpected death of a paediatric patient than clinical event debriefing.
      I guess I chose the article because despite this, this is an article that is likely to be cited as evidence against implementing clinical event debriefing programs, and as such I think it’s worthy of discussion in terms of knowing what evidence is out there with regards to CED, both pro and con.

      A couple twitter discussions have come up recently regarding this, and a strong, seemingly universal opinion was that while all staff should be invited to these things, it should never be mandatory. I agree that stress management and coping techniques are a very individual process.

  • Sonia Twigg

    This study asks interesting questions;
    – Does being involved in a child’s death cause (or contribute to) Acute Stress Reaction ASR or Post Traumatic Stress Disorder PTSD in paediatric trainees?
    and
    -Can we identify any factors that make this worse or better? In particular, does clinical debriefing decrease the rate of ASR/PTSD?

    I was annoyed and intrigued by this study. I like the questions it poses. I applaud the authors for their efforts in answering them. But I did not think their measures or the survey method used in their study could answer these interesting questions.

    This study echoes one of the underlying questions we are still asking;
    Does clinical debriefing help or harm?
    Or both?

    The AHA in 2010 recommended that clinical debriefing be done after resuscitation due to evidence of better patient outcomes in teams that use it. Kessler in his 2014 review of clinical debriefing lists these as improved neurological outcomes, less delay to CPR, less hands off time and increased rate of ROSC.

    So we have evidence that clinical debriefing helps improve performance.

    Certainly I think of examples in my career in which a clinical debriefing after a stressful resuscitation was helpful – it helped me defuse, understand what had happened in a complex case, and reflect on how the team and system could improve in a meaningful way. I felt closer to the team by the end of it. I had not reflected on whether it improved team performance.

    The quoted cochrane review by Rose et al in 2002 looked at 15 studies (an analysed data from 9 studies) of single session psychological debriefing type intervention for a single individual who had been a victim of trauma – compared to controls or an education session. This is a very interesting review of studies that tried to include high quality, randomised studies. They found no improvement in rates of PTSD. One study reported clearly increased rates of PTSD. Rose et al concluded that clinical debriefing should not be compulsory. Their results were consistent with previous reviews on psychological debriefing. They did not look at group debriefing. Participants did not include health or emergency personnel. In the discussion, they discuss why clinical debriefing might cause harm. They observe that every treatment can have adverse effects in an individual – and that there could still be system benefit in terms of management of the critical incident. They discuss the “secondary traumatisation” phenonomenon – in which reliving the stressful incident through imaginal exposure may increase symptoms. They also discuss how shame may be a risk factor for increased symptoms after a psychological debrief.

    The quoted cochrane review by Roberts et al in 2009 looked at a range of multiple session brief psychological interventions aimed at preventing PTSD – these did not include clinical debriefing, in a varied population of people who had experienced a traumatic event – none of which were health professionals. They found no improvement in rates of PTSD, but a trend towards increased self report of symptoms of PTSD 3-6 months after the event.

    So at an individual level, we have no evidence that clinical debriefing protects against PTSD.

    I can think of examples in my career of clinical debriefing sessions in which I felt uncomfortable and not safe to say what I really thought or felt. These sessions were run by inexperienced facilitators, the aims and structure of the session were not clear to me, and I was a lot more junior at the time – with less understanding of the process.

    Saying clinical debriefing does not protect against PTSD is different to saying it does not help, and different again from suggesting it may harm.

    I am also not convinced that the rate of ASR/PTSD gives us enough information. The measure picks up only severe individual reactions, may be affected by multiple confounding factors – and does not tell us about the effects on the team, system or overall patient outcomes.

    In this survey of paediatric trainees in the UK, of whom 90% had experience the death of a child, there was a 9% point prevalence of symptoms of ASR and 5% of PTSD but participants who attended a debrief were more likely to have symptoms suggesting ASR or PTSD than those who had not attended a debrief (20% vs 10%). It seemed there were problems with these debriefing sessions – facilitators seemed untrained and the quality and methods of the debrief not measured. We should also note that these trainees did not receive a formal diagnosis of ASR/ PTSD – the condition was suggested by the number of symptoms they agreed they had on the survey so we may not be able to compare this to other studies looking at rates of ASR/ PTSD.

    In fact, if we did use the rates given, the trainees in this study had lower point prevalence rates of PTSD than the general population (5% vs 8%). However, the authors suggest these trainees are not yet old or experienced enough to reflect an accurate lifetime prevalence of ASR/PTSD – which may explain this difference.

    The study also recorded some saddening observations of the trainee’s experience – trainees had not received training in how to do a clinical debriefing, the majority did not feel they were ready to cope with the death of a patient, and many felt they were expected to return to work before they were ready. They also found an association between a feeling of guilt and symptoms of ASR/ PTSD.

    I think we need to start doing and training in clinical debriefing as part of regular practice, and to keep asking questions and doing research to establish the effects of it. In what ways does a clinical debriefing session help? What are useful measurements? And what are the effects at the level of individual, team, system and outcomes for patients?

    Then we can be clearer about what we can meaningfully achieve and how to do it.

    • Victoria Brazil

      Thanks Sonia for a very comprehensive summary.

      Like you, find this article not especially helpful guidance due to a) the causation/ association issue, the b) ‘chicken and egg’ issue ie do symptoms of ASR/ PTSD somehow affect attendance at debrief, and c) the survey measure.

      Dealing with ‘the debrief’ as a consistent, uniform entity is problematic. The low prevalence of clinical debriefing even after critical events like child death is part of why we are struggling with this. We’re not sure whether the discussions are focused on performance improvement or psychological recovery or some combination of both. Are only deaths or critical incidents debriefed, or is this part of routine clinical ‘after action review’ for performance improvement. (and I don’t just mean in the study)
      But these are the realities of retrospective cohort studies and also like you, glad the authors have had a go and done some thoughtful work.

      I wonder whether a routine, short ‘after action review’ following pre-identified events, with teams reviewing positives and clinical areas for improvement, but flexibly cognizant of psychological impact/ distress might make everyone more prepared for team conversations when there is a larger ‘burden’ eg after paediatric death?
      And yes training for facilitators, but also just consistency and cultural norm…
      #dreamon ??

  • Victoria Brazil

    and…. Just reading through these two articles given to me by Laura Rock.

    Use of debriefing after surgical cases primarily for quality improvement

    https://www.ncbi.nlm.nih.gov/pubmed/29606010

    https://www.ncbi.nlm.nih.gov/pubmed/29580254

    The extent of performance improvement ( including 33% reduction in surgical inpatient mortality) is astounding.
    So this adds another angle to the cost benefit of ‘after action review’.
    I’m not sure it is a tradeoff… but what if we are deciding between clear patient benefits versus the possibility of harm to practitioners?

    imo – we can achieve both positives if clarity around the purpose and approach of clinical debriefings

  • Katie Reeves

    Hi Team,
    Long time listener, first time caller.
    I was interested in “guilt” being raised frequently, and what this meant for those trainees which was different to the other symptoms being measures, but don’t feel as though this was explained well.
    What about the experience of Acute stress reaction (ASR) being a normal response? Sometimes I believe we are sending the message out that you are not allowed to feel stressed if you are involved in a death of a patient. I think we should be allowed to normalise some of these responses instead of measuring our ability to withstand these emotions that actually help our complex brains process what is not a normal experience.
    I agree that PTSD should be assessed, but these are symptoms which are pervasive, beyond 1 month. I don’t think that putting both ASR and PTSD together is helpful here.
    In your debriefing system, if you are only debriefing deaths, which I find are always difficult in paediatrics , then you are having the impact of a debrief as well as a death to deal with. I really think that a good debriefing system should have a set trigger, which includes patient death, but also all CPR, intubations, trauma responds, which then allows the debriefing system to practice regularly after these disruptive events. I also believe that it is important to not just debrief adverse situations but also discuss the achievements and wins. This can assist in debriefing becoming more of a system approach, accepted practice, and less challenging when there is a death to discuss.
    I agree that instead of ad hoc, there should be a set structure, with facilitators that are trained specifically in this. Often, we have staff that have an interest, or whose role (social work, emergency consultant) leads them to naturally take on the debrief. This does lead to variability in approach. I agree there can be harm sometimes, I have seen well intentioned staff trying to help but missing the mark.
    I am formulating a debriefing program for our hospital, and this has given me plenty of inspiration for the structure as well as evaluating our system and participants.
    Looking forward to further discussion,
    Katie

    • Ben Symon Post author

      Katie! Thank you so much for coming along!
      I appreciate all your insights, in particular the implicit danger of measuring the alleged trauma of a debrief process by only debriefing the most challenging and upsetting of cases. I hope to hear some more wisdom from you in the future!

  • Ian Summers

    Hello Ben and others,

    I am reminded as I read comments on twitter regarding the sad stories of harm perceived as being created by debriefing of the length that you and Vic and Liz Crowe and I went to in separating and defining the different aspects of clinical event debriefing in preparation for our DFTB workshop. And it was hard work! The risk of bundling immediate and delayed, hot and cold, psychological first aid, quality improvement and raw emotional events together as one overarching “debriefing” is tempting, but ultimately misleading. They exist on a spectrum of emotional charge, risk, availability, duration post event, in-team lead vs outside provider, facilitator comfort, training and expertise and rather than lump them all in together, we should see them as an overlapping continuum we can divide up to add a little more meaning to the discussion. Ben, I hope you can provide your arbitrary but rather useful table with division of aims and differences between the extremes. If we add the concerns of the validity of questionaries on PTSD (come on Liz, add your comments here!) then it all becomes even more of a mess. So congratulations to the authors on taking on such a challenging question, but I scratch my head and try to make sense of the conclusions knowing just how difficult it was to make sense of what is defined and what we all mean by clinical event debriefing. It makes studies where this is tightly defined as an intervention even more valuable, and yes I love Vic’s idea of adding patient outcomes to the risk-benefit analysis, and to the degree of value, meaning and commitment we might give to a routine, immediate, quality-focussed clinical debriefing programme.

    Yours (in adding more uncertainty to the discussion!)

    Ian

    • Ben Symon Post author

      Thanks Ian! I agree the complexity of clinical event debriefing makes it very hard to synthesise our goals and measurable outcomes. This is complex, nuanced stuff and we are understandably very much in our infancy with respect to any publication or research on the matter. I applaud the authors for starting a conversation despite my disagreement with their recommendations.

  • Noel Roberts

    Hi all,
    Thanks for the interesting discussion.
    The article raises many interesting issues but the methods don’t allow it to reach meaningful answers.
    As they identify their questionnaire cannot accurately identify ASR or PTSD.
    They also grouped together ASR and PTSD to assess the association with guilt and debriefing.
    As you have already discussed many of the symptoms of ASR seem entirely “normal” and part of the recovery process.
    It would seem more important to assess rates of PTSD and associations, I couldn’t find this in the article?
    The authors suggest feelings of guilt should be identified and followed up. I wonder how this might occur without some form of debrief?
    It is a real stretch to suggest that “debrief after the death of a child may be associated with the development of symptoms suggestive of ASR/PTSD.” There needs to be much more definitive evidence regarding the potential harm of debriefing before it is discouraged given the benefits of debriefing regarding quality improvement and team performance already alluded to. My personal experience also supports the benefits of debriefing for the individual having experienced the “non debriefing, she’ll be right” and debriefing approaches. I’m really interested to hear about the approaches Katie instigates in her institution.

    • Ben Symon Post author

      Thanks so much for your observations and comments Noel, I really appreciate you coming along! I’ll prompt katie irl to expand further on her plans in her hospital.

  • Jesse Spurr

    Great discussion this month. I have been lurking and trying to keep my own biases at check. But I couldn’t. I have read and reread this paper and can’t for the life of me figure out why they even tried to make comment or recommendations regarding debriefing. This belongs with the other methodologically flawed (edited – studies) that populated the Cochrane review. The (very weak, underpowered and statistically questionable) association between debriefing attendance an higher symptomatology of ASR/PTSD would seem very logically confounded by the fact that cases which were a bit of a dog’s breakfast tend to be more likely debriefed and certainly are the ones where work will stop to facilitate debriefing (a major impediment to attending debriefings, noted in this study).
    It’s unfortunate, because I think the rest of the paper was pretty good and the authors should have stuck to looking at what their study title was – Impact of child death on paediatric trainees. I think the insight into the frequency of ‘guilt’ being a labelled valence is really important as this, in my mind provides further impetus to address psychological first aid training and develop debriefing skills in all clinical team leader roles. The thought that not talking about feelings and reflecting on a situation does anything to attenuate guilt is peculiar.
    So fair to say this study will not change my practice of trying to increase the practice of after action reviews (hot debriefs) and ensure that the team has a shared understanding of what happened.
    I apologise for my emotive tone, I hope I don’t have a quasi-statistically significant increase in my self reported ASR/PSTD symptoms after sharing this debriefing with you all.

  • Kate Bassett

    Some great comments here, I have enjoyed reading and learning. I was politely prompted to join the conversation and not just take from it! So here goes! I have enormous respect for the people who have commented and therefore little to add regarding methodology of the study. My thoughts on the topic mirror what has already been said to some extent.

    Firstly, I worry that in our desperate search for wellness we seek a one size fits all solution to the psychological traumas we encounter. Where I work – all streams are invited to the debrief and I worry that times when our medical minutiae focus has offered me comfort; it has done little to help our operational colleagues. I also reflect on times when my position in the event has led me to feel obliged to contribute when I really just needed time to digest and organise my thoughts. I have never felt harmed but have felt burdened by the process.

    Secondly, a paediatric death is a terrible tragedy so if that is the first time we look into ourselves and our workplaces to find ways to heal then it is hard to see that whatever debriefing we offer will be helpful. Surely a debrief can only offer a refection on the events and a reminder to practice whatever we have in our resilience toolkit. We need to be given that toolkit early. Our work lives are a continuum of micro traumas that build up in our psyche: the professional discourtesy from an overworked and angry colleague, a failed procedure, heaven forbid the harsh words of a loved one who craves more time from us. We must learn and teach methods of managing the small things so the muscle memory kicks in and help us when the tidal wave crashes over us in difficult clinical situations.

    I have had the good fortune to be involved with some highly skilled “debriefers” and what I notice most about them is that those skills are evident in all of their interpersonal interactions – not just “sessions”. We all need to learn how to do it for each other but I think it’s OK to be good at it one on one – you don’t need to be the group lead. Most importantly we need to rally against the idea that a debrief is “the box ticked” after a traumatic event – for those that are hurting it is just the start of a long road

    • Ben Symon Post author

      Kate thank you so much for coming along, I didn’t know you even read the journal club!
      There’s so much in your comments that I’m reflecting on, from “in our desperate search for wellness we seek a one size fits all solution to the psychological traumas we encounter.” to “It’s OK to be good at it one on one”.
      Your post really highlighted those points to me in a way I hadn’t thought about.
      I agree that supporting a clinical event debriefing program could become reductionist, pointless ‘box ticking’ if done incorrectly.
      Much to muse.
      Thanks!

  • Joy Domingo-Bates

    Thank you for the opportunity to make a comment, and I am sorry for the delay. Four of the Mater Education Simulation Team came together and discussed this article. It is an interesting article that made us really think through the issues.

    Let me start with the strengths of this paper:

    -I applaud the authors for this paper as it is a very relevant topic nowadays. We all know that in the last 2-years, the talk about the mental well-being of health care professionals prevails; hence this paper is in time.
    -The objective is clear.
    -The authors acknowledged the possibility of selection bias.

    Issues worth exploring:

    -Are the paediatric trainees appropriately represented in this study? What were the reasons why 50% did not respond to the survey? It is interesting that they have limited their participants only to the paediatric trainees. When I was asked the question when we were discussing this paper, my response was “sure, I can consider doing the same research on my neonatal trainees as well”. I guessed my reaction was based on the limited training I got dealing with neonatal death, and I just wondered the impact of neonatal death to the other junior trainees. However, as I reread the paper, the participants came from different levels of their training. Moreover, most have experienced child death more than once. It is interesting to find out whether the psychological impact was worse for the more junior doctors (ST1-3). Did the more senior trainees get less affected since they have gained more experience? Does the extent of involvement of a trainee in the care of the dying patient counts, whether it is an ED death, ward death, or palliative care death?
    -It is qualitative research. Though the survey is maybe appropriate approach for the research question to illuminate the subjective experiences of the research participants, we just wondered whether another theoretical approach could have been used to better justify about the research question of the study.

    -We find linking the debrief experience to this paper is a risk. Debriefing after the critical event, is it harmful or not? Based on the article, paediatric trainees responding to this survey showed an increasing prevalence of symptoms suggesting PTSD after a debrief. Question is what the primary purpose for the debrief is? Is the debriefer experienced and competent in debriefing? Unfortunately, this was not stated in the paper. Hence based on this article, we cannot agree that debriefing is psychologically harmful to the trainees who experienced child death. Being both a clinician and an educator, we believe that debriefing needs to be done by an experienced and competent debriefer at the right time.
    – We also discuss the meaning of guilt in this situation. Is it just a normal emotional reaction after an event. Is it enough to associate it with symptoms of PTSD and ASR?
    – Lastly for the trainees that they have picked up signs of ASR and PTSD, what measures have been done to manage the trainee?

    The final thing we considered was the idea of relevance to simulation. Yes sim educators are increasingly being asked to have input into the design and implementation of clinical event debriefing – but are the skills we have in sim ed debriefing really transferable to clinical event debriefing? We thought “yes” from a creating a psychologically safe environment point of view, but perhaps “no” regarding other aspects. In sim, as educators we observe the performance directly with a clear understanding of performance expectations, and the purpose of the debrief is to close negative and sustain positive performance gaps. This may not be the case following a complex clinical event, particularly in the setting of an unexpected death – where improving performance gaps may not be the primary aim. In fact, highlighting performance gaps which may increase feelings of guilt could (according to this paper) be a risk. There may also be additional legal implications that educators are not trained to negotiate when a sentinel event has occurred – can the “Vegas” rule of the debriefing really be applied when participants may be called to give evidence in a future case? This is worst case scenario of course, but we want to highlight this to caution those who think that a clinical event debrief is “just the same” as a sim debrief. We don’t think they can be – and look forward to some future scholarly work that outlines the similarities and differences.

    • Ben Symon Post author

      Joy! It’s so lovely to hear from you and that the mater team curry and journal night went ahead! Thankyou for your comments and sharing such detailed thoughts😊

  • Shannon McNamara

    So many insightful comments above! Thanks to all for engaging in such a thoughtful manner. Overall, I’m grateful to the authors of the study for engaging on this important topic, but think the methodology limits our ability to draw any causal inference between debriefing and harmful stress.

    Having experienced the arc of learning sim debriefing and applying it extensively to clinical debriefing in the last 5 years, I agree with many of the comments above about the process. Specifically:

    1) clinical debriefing is a different practice than sim debriefing, even if the structure is similar. Agree with best practices like making it optional, short, immediate, and after routine events like intubation/codes (ie process oriented not outcome oriented, less likely to be perceived as punitive).

    2) trying to completely separate operational/preformance improvement debriefing and psychological debriefing is impossible – they coexist on an inseparable continuum. A debrief may lean towards a particular objective, but it’s not possible to ignore either element.

    3) These conversations are risky, and deeply important. They should be optional and treated with respect and reverence. I used to avoid them due to fear of causing harm. Now I realize that people often need to talk about these cases in the moment. I think it’s better to lean in and try to talk about them as best we can, even if it’s not perfect.

    The area of deepest uncertainty I’ve found is around preformance assessment when the patient experienced an adverse outcome. The typical “how could we have done better question” is particularly loaded here.

    If we had done better, would the patient have experienced a better outcome? If we had done more, would the patient had lived? Am I responsible for this patient’s death or injury? How do I bear the responsibility for inadvertently harming someone or failing to rescue someone that I was trying to help? Especially when my professional identity is defined by my ability to heal?

    Finding self compassion and forgiveness in those moments of uncertainty can be incredibly difficult.

    Witnessing death and suffering is hard enough. What happens when you start to wonder if you made it worse? We don’t often learn to manage the shame and guilt that may appear in these moments. Medical training & patient safety unfortunately often pile on more shame around error. Debriefing may make that worse if done poorly, which I imagine may augment existing ARS/PTSD symptoms.

    Ultimately, I think that most clinicians that witness a child’s death will experience some sort of traumatic stress. Whether or not it amounts to levels meeting criteria for ARS/PTSD, coping with that stress is an important part of the debriefing process.

    I have not seen conclusive evidence describing the best way to lead an immediate clinical debrief after a child’s death. But I have seen conclusive evidence that after a child’s death in the ED, there are many staff that want to talk about it.

    • Ben Symon Post author

      Shannon thankyou so much again for your wonderful, thoughtful and compassionate comments! I agree with them all and have little to add beyond appreciation for your time!