A Roadmap to Teach Senior Residents to Facilitate Debriefings

after Critical Incidents Amanda D. Osta, MD Janet R. Serwint, MD

Megan E. McCabe, MD Annamaria T. Church, MD

Albina S. Gogo, MD Ann Burke, MD

Disclosures

• The authors have nothing to disclose • AAP is providing funding for editorial overview

of curriculum

Objectives of Workshop

• Identify critical incidents following which debriefing sessions for residents would be beneficial

• Conduct a successful mock resident debriefing

session • Implement a debriefing curriculum at your

home institution

Agenda Activity Time

Welcome and Introduction to Curriculum 10 minutes

Journaling Worksheet •Followed by pair-share

20 minutes

Overview of Debriefing 10 minutes

Mock Debriefing Case 30 minutes

Small Group Discussion 15 minutes

Large Group Discussion 10 minutes

Steps for Implementation 15 minutes

Wrap Up and Evaluation 10 minutes

Invitation to Create Curriculum

• AAP Section of Medical Students, Residents and Fellowship Trainees

• Need to address grief and loss • AAP Section on Hospice and Palliative Medicine • National call for participants/authors • Development of curriculum to address resident

grief and loss • Revised to approach through resiliency

Why Is This Essential?

• Pediatric residency incredibly rewarding time in career

• Yet, can also be quite demanding for housestaff

• Implementation of new work hours has increased workload intensity, and potential for emotional detachment

Why Is This Essential?

• Distancing (withdrawing from family) while immediately protective, may lead to personal disappointment and burnout

• Trauma of events impacts residents • Long term implications may include mental

health issues, substance abuse

Why Is This Essential?

• Being engaged with patients and families results in some of most rewarding experiences

• Relationships with families and addressing

suffering key to our profession • Engaged and vibrant pediatricians must develop

skills and cultivate mechanisms to maintain wellness by being present to human interactions in dynamic and mindful ways

Why Is This Essential?

• Two resident physicians in two different programs in second month of training in NYC committed suicide in August 2014

• Physicians have higher rates of depression, anxiety,

substance abuse and suicide compared to the general population – Pediatric residents have 20% rate of depressive

symptoms

Components of the Resilience Curriculum

• Part A: Understanding Grief and Loss

• Part B: Communication with Families about Critical Incidents and Life Altering Diagnoses

• Part C: Adaptive Behaviors and Coping; Mechanisms

for Health Care Providers

• Part D: Maintaining One’s Own Wellness

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Tools developed for each module

• PowerPoint presentation- for self study or group discussion

• Learner and faculty guide • Cases • Reflections • Experiential components- - Videos - Articles, narratives - Scenarios- role play or standardized patients

Senior Resident Debriefing: Objectives

• Identify situations which debriefing sessions would be beneficial

• List benefits of a debriefing session • Recognize the need for debriefing and support in others • Conduct a successful mock debriefing session

– Analyze the event – Identify one’s own emotions – Inquire about perceptions of family and medical team members – Ask critical questions to help team members reach closure – Comment on how medical team member responses may affect patient

and family interactions

Reflective Exercise

Think about a patient care experience when:

– one of the trainees working with you had an emotionally challenging experience

OR

– you were in that situation as a trainee

Complete the journaling worksheet provided

Share with the person sitting next to you

Facilitated Discussion

• Would anyone like to share their story?

• If you were involved with the patient, did you experience the event similarly to those you were supervising?

• What did you take away from this experience?

• Did you or the trainee participate in a debriefing after this experience?

Background

Multiple national organizations have recognized and supported the needs of physicians dealing with grief and loss.

• IOM report: ‘‘When Children Die’’ • AAP Statement on Palliative Care • APA Educational Guidelines

Background • In a study examining pediatric resident use of

debriefing after a patient’s death: – 31% of residents acknowledged guilt – 74% of residents debriefed after at least one

patient’s death – Residents stated that they had debriefed after

30% of patient deaths – Higher odds of debriefing with:

• Inpatient death vs. ED death • Death of a previously healthy patient vs. death of a

patient with chronic disease Serwint J. One Method of Coping: Resident Debriefing After the Death of a Patient.

J Pediatr August 2004

Debriefing Primer

Critical Incidents

• Patient death or sudden decompensation • Life altering diagnosis • Unexpected outcome • Uncertainty • Inability to control outcomes • Medical error • Angry family Lead to strong emotional reactions that have the potential to

interfere with ability to function, either initially or later

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Critical Incidents During Medical Education and Practice Impact Us

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Benefits of Debriefing • Taking time together to identify the personal

impact of grief and loss

• Increased mutual understanding and empathy among group members

• Acceptance of normal responses to distressing situation

DR Hanna, M Romana Debriefing after a crisis What’s the best way to resolve moral distress? Don’t suffer in silence. August 2007 Nursing Management 20

Benefits of Debriefing

• Validating experiences and responses frees clinicians to return to their work on behalf of others

• Healthy coping skills of some group members shared with those who coped less effectively

“We have an obligation as educators to share with learners how we have coped

with feelings of anger, anguish, shame or uncertainty in caring for patients.”

-Novack DH et al. Acad Med, 1999

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A Framework for Debriefing

Welcome and Introductions

• Review purpose of bereavement debriefing sessions • Invite participants to give names and answer the question: “How were you involved in care for this patient and family?”

Factual Information • Review time of death circumstances Case Review • What was it like taking care of this patient?

• What was the most distressing aspect of the case? • What was the most satisfying aspect of the case?

Grief Responses • What have you experienced since the death? (Elicit physical, emotional, behavioral, cognitive, or spiritual responses)

Emotional • What will you remember most about this patient/family?” Strategies for Coping with Grief

• How are you taking care of yourself so you can continue to provide care for other patients and families? • Review grief coping strategies • Review available resources

Lessons Learned • What lessons did we learn from caring for this patient/family? Conclusion • Acknowledge care provided

• Review bereavement support available for families and staff Elizabeth A. Keene, Nancy Hutton, Barbara Hall, Cynda Rushton

PEDIATRIC NURSING/July-August 2010/Vol. 36/No. 4

Mock Debriefing

• Case Introduction • Case Discussion • Mock Debriefing • Debriefing Discussion

Mock Debriefing: Case Introduction

• First week in July

• Pediatric cardiology team

• 7AM: Katie, a 4y/o girl with idiopathic pulmonary hypertension presented for routine yearly cardiac catheterization

• Procedure performed by her primary cardiologist goes well

• Plan for discharge later in the evening or next morning

• Intern who admitted her in the morning, signs her out to co-intern for discharge once cleared by cardiology.

Mock Debriefing: Case Introduction

• 8PM: Pulmonary hypertensive crisis

• Patient codes and dies. No one from primary team is present

• Team is rounding the next morning

Mock Debriefing: Case Introduction

• Intern 1 • Usually on top of things and highly motivated • Appears a bit scattered this morning

• Intern 2 • Never saw the patient after receiving sign-out • Feels that if she had seen patient, she could have

noticed something, and perhaps this would not have happened

Roles for Debriefing

Roles for debriefing • Senior resident (leader) • Intern 1 • Intern 2 • Observers (use the skills checklist)

Practice Scenario

• Use the skills checklist to note specific skills • Consider what you will ask your group at the

end of the session: - What skills did you notice? - What went well? - What was challenging? - Feedback for the debriefing leader?

A Framework for Debriefing

Welcome and Introductions

• Review purpose of bereavement debriefing sessions • Invite participants to give names and answer the question: “How were you involved in care for this patient and family?”

Factual Information • Review time of death circumstances Case Review • What was it like taking care of this patient?

• What was the most distressing aspect of the case? • What was the most satisfying aspect of the case?

Grief Responses • What have you experienced since the death? (Elicit physical, emotional, behavioral, cognitive, or spiritual responses)

Emotional • What will you remember most about this patient/family?” Strategies for Coping with Grief

• How are you taking care of yourself so you can continue to provide care for other patients and families? • Review grief coping strategies • Review available resources

Lessons Learned • What lessons did we learn from caring for this patient/family? Conclusion • Acknowledge care provided

• Review bereavement support available for families and staff Elizabeth A. Keene, Nancy Hutton, Barbara Hall, Cynda Rushton

PEDIATRIC NURSING/July-August 2010/Vol. 36/No. 4

Debriefing Feedback

• What skills did you notice? • What went well? • What was challenging? • Feedback for the senior resident who is running the debriefing?

Additional Questions

Questions • Who should/could ask for a

debriefing? How? • When should a debriefing be

done? • Who should be present? • Who should facilitate? • What is the role for the

residency director?

Potential Participants •Medical students •Interns •Senior Residents •Fellows •Attendings •Residency Director •Clerkship Director •Pharmacy •Social Work •Environmental services •Other disciplines

Implementation Steps

• Potential opportunities for implementation? • Barriers for implementation?

Next Steps

• We’ll email a link to workshop materials and the overall trainee resilience curriculum

Authors of Curriculum Collaboration with AAP, APA, APPD, COMSEP

• Janet Serwint (Johns Hopkins U) • Susan Bostwick (Weill-Cornell College) • Ann Burke (Wright State U) • Annie Church ( U of TN- Chattanooga) • Albina Gogo (UC-Davis) • Dena Hofkosh (U of Pittsburgh) • Marta King (St. Louis U)

Authors of Curriculum

• Jenni Linebarger (U of TX-Houston) • Megan McCabe (Montefiore ) • Margaret Moon (Johns Hopkins U) • Amanda Osta (U of Illinois-Chicago) • Deborah Rana (UC- San Diego) • Florence Rivera (AAP administrative staff) • OJ Sahler (U of Rochester) • Keely Smith (U of Missouri-Kansas City)