the debrief imperative
TRANSCRIPT
The Debrief Imperative
A portable support program for clinical providers
Vickie Leff, LCSW, ACHP-SW, Clinical Social Work, Palliative Care
Duke University HospitalSWHPN 2016, Chicago
Goals and objectives for today…
• Identify emotional support needs and barriers for clinical
providers in PC/Hospice
• Define pathway to design and implementation of debriefings
any PC/Hospice setting
– Administrative strategies
• Offer tools to put together your debriefing group
What kind of Group?
Monthly facilitated groups for providers working with critically ill patients, dying patients and difficult deaths
– Offer safe and neutral atmosphere to discuss emotional and personal impact of difficult work
– Use collegial comradery to strengthen team communication and support
– Identify strategies for resilience such as: self awareness, self care techniques
Debriefings at Duke
Who/Where
• Monthly Hospital wide House Staff around difficult deaths
• Monthly Pulmonary Step-down unit for Nurses
• Monthly Oncology Unit for nurses• Cardiac Intensive Care Unit - nurses• Thoracic Surgery Floor – nurses (LVAD’s)• ER Pediatric nurses• Pediatric Neonatal Intensive Care Unit –
all staff
Co-Leads along with CSW?• Pall Care Clinical Director
(MD)• Unit Lead RN/PA• CSW only• CSW only• NP Pall Care• CSW only• Pall Care MD
Contributing domains
Michael and Enid Balint Irvin YalomMilitary Debrief
London, Balint Groups, 1970’s Airforce debriefing Group Psychotherapy
Why Debriefings?
• Compassion fatigue and burnout are high in health care
• Debriefings can build this skill
• CSW have specialized skill set to deliver this tool
• Elevates visibility and role for CSW
• Proven method of protecting against this is self-awareness
• Applicable to variety of providers
• Can be done in any environment (in-pt, outpt, hospice)
• Practice to full scope of practice
Why it’s important How it helps
Why Debriefings?
• Reduces possibility of psychological harm
• Improves opportunity for resilience
• Allows for emotional recovery
• Validation from peers• Normalize feelings • Learn from others
• Processing events helps to avoid the merging of traumas leading to cumulative stress
• Attendance varies, inconsistent
• Support Group requires consistent participants
Parachute in!
PERFECT OPPORTUNITY FOR CLINICAL SOCIAL
WORK!!!
Debriefings Overview
• Confidential
• Facilitated
• No rank or seniority
• No right or wrong
• No interruptions
• Differences are expected
Not therapy
Voluntary
Differences are
expected
Everyone is equal
rankless
Key ingredients to success
• Environment is safe and structured
• Re-telling of emotional details and reactions
• Involves emotional expression
• Provide validation
• Provides opportunity for meaning making
• Strengthens self awareness - resiliency
Underlying Goals and Hopes
• Build self awareness
• Identify self care strategies
• Team communication
• Team support
• Identify barriers
• Identify solutions
• Provide opportunity to grieve
• Encourage finding meaning• Model support and
communication techniques• Identify symptoms of burnout
and secondary trauma (education)
• Learn self reflection skills• Create, develop and nurture
supportive culture
GROUP THEMES
• Isolation
• Boundaries
• Sadness
• Anger/frustration
• No time to process
• No time for self care
• individual methods for stress relief
• Having, wanting, input to care
• work-life balance;
• high learning curve stress;
• first death experience;
• how to talk with patients/family during dying process;
• sharing personal lives with co-workers;
is burnout common in
medicine?
45% physicians
51% residents
34% hospital nurses
Shanafelt et al. Arch Intern Med 2012. Shanafelt et al. JCO 2014.
McHugh; Health Affairs 2/2011 202-210
West, JAMA, 2011, 306 (9)
Nurses – at high risk
• Provide physical, emotional
care
• Intense professional
relationships with pts/families
• Protracted exposure to
suffering and death
• Create strong therapeutic
bonds
• Providing care in complex
disease processes
• Working with a team
• Shift work
Hospice Nurses
Abendroth, JHPN November 2006 vol 8
Risk Factors
• Inability to debrief
• Blurred professional
boundaries
• Sacrifice “own needs”
in difference to patients
22 Florida Hospices, n = 216
78%moderate to high riskof compassion fatigue
Setting the stage
• How did this start, who was involved, where did it happen?
Putting together a plan
• Getting out ducks in a row: first, find the ducks!
Examples
1. House Staff Death Debriefing
2. Pulmonary Step Down unit Nursing debreifing
Debriefing the House Staff around difficult deaths
• Began as a talk for grand rounds• House staff wanted more• DR. G. told me about, I invited myself and skill set• Dr. G. worked with hospital administration to get buy-in (head of
medicine program) identifying need• Relationship Dr. G had with house staff over 25 years made this easy• Found a time ok with admin• Found location• Publisized to house staff with Dr. G. as the Marquee Star
Outcomes
• Research
• Editorials
• Report submission
• Led to developing more debriefings in MICU and SICU among residents/fellows
• Started in 2013
• Monthly Meetings
• Attendance from 2-10 each time
• Consistent themes
• Changing the culture
Nursing Identified Problem: Staff Distress
• Complex young patient
• The emotional toll wrought by this experience made it obvious that the team needed to debrief in order to recover emotionally and continue professionally.
Began to seek out more opportunities for this type of discussion.
Why develop a debriefing program?• Seeing the benefits from the house staff debreifings
was informative• Wanted to open lines of communication between the
medical staff and all of the other team members involved in the care of our patients.
• With these barriers broken down, we heard about patient issues sooner, heard about more than just medical issues but social and psychological issues as well
Key support people
• RN Clinical Lead
– Continuing high turnover
– Background in education
– Solid relationships with management
• Pulmonary PA
– Special interest in resilience and combating burnout
7800 Unit Characteristics• 28 private patient rooms• Patient Acuity:
– ventilator-dependent long term – sub-acutely ill patients – short term general medicine patients
• general medicine services, the general pulmonary service and the pulmonary transplant: – pulmonary hypertension on continuous
drip medication, – pre-transplant patients with high oxygen
needs and or – severe infectious diseases requiring
inpatient care, – post-transplant patients with multiple
surgical and non-surgical complications, and
– young chronically ill pulmonary patients with complex social issues.
Why was it successful?
• discussing SOS with the PA/NP team and the attending, we got only support.
• The better our interrelationship, the better care our patients would receive, the better the outcomes (whether in living or in dying) and the more meaningful our work
• transplant attendings were supportive and the PA/NP team supportive of my involvement.
HOW: The Logistics• Approval from Mgmt
– 7800 Nurse Manager and the COO were approached by a unit floor nurse about her concern for the turnover rate and high amount of burnout/fatigue shared by her colleagues. I laid out a plan developed in collaboration with Tanya Arbogast, PA (7800 pulmonary transplant) and Vickie Leff, SW (palliative care team and frequently working with patients/staff on 7800).
• Buy in from staff - including PA/NP team
• Literature Review; MaslachBurnout info
• Marketing Program - email, texts, posters, huddle, word of mouth
Consequenses
• Changing the culture- some resistance/non-interest from staff with 5+ experience;
• Coaching program encourages participation for new nurses
Logistics and Money
• Finding the time – and right time
• How often
• On campus/off campus
• How to reach all shifts
• Length of group (30-45 min?)
• Offer food? (YES!)
• Location, location, location
• Offer didactic materials
• Learners/observers?
Marketing and Buy In
• Management and Administration support
• Doesn’t cost anything
• Increases retention ($$$)
• CSW presence ensures clinical veracity – don’t have to teach provider type
• Used circumstances and examples from providers and recent suicide of resident for motivation
Group Dynamics
• Sharing
• Confidential
• Safe
• Non threatening
• No judgement
• Group Primer
• Balint Groups
• Need for Facilitator – can’t anyone do this?
Your Role
• What’s your role?
• When is it appropriate to refer out
• When is there need for follow up?
• Listen and validate
• No judgement
• No platitudes
• Identify strengths
• Reflection
• Offer strategies if/when needed (i.e. reflective writing)
• Normalize emotions
Debriefing skills
• Recognize limitations of the group (not therapy)
• Set realistic goals for the group
• Clinical supervision for self care and education
Debriefer Don’ts
• Blame
• Bring up past traumas
• Advise giving
• Escalate anger
• Feed the struggle
The Debrief Meetings: parameters
• Relaxed, informal atmosphere
• Reminded of confidentiality
• Begin each with stated purpose: “We know this work is hard. It’s
important to find time to give voice to our own reactions and feelings in order to continue to do this work for the long haul”
• Self-sharing about difficulties
• Offer reflection/clarification/normalization
• Look at strategies for resilience
Portability and tools
Steps to take
• Identify need• Survey staff• Identify RN champion• Find facilitator• Management buy-in• Team support• Normalize opportunity (doing this
everywhere)• Provide evidence – lit review• marketing
1. Get started
2. It will take months
3. Budget
4. Location
5. Determine title: Shot in the Arm, SOS, Debriefing
References
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