By Victoria Brazil (@SocraticEM)
I’ve been an avid proponent of in situ simulation – done in the actual clinical environment – for improving team and systems performance. The teams, the equipment, and the communication processes are authentic, and encourage a debrief that is focused on practical, real world ways to do better.
Three hundred patients a day come through the doors of my emergency department. I’ve started to wonder why I have to create a fake one to have a conversation with individuals or teams about how we can improve?
Simulation debriefing – reflective conversations following or during a simulation – is perhaps one of the key contributions of healthcare simulation to the health professional education and quality improvement communities. How to close performance gaps through these conversations has formed the basis of a large body of literature. ‘Learning to debrief’ has become an important goal for simulation educators.
So perhaps we can take the skills, conversional structures and underpinning theoretical principles from simulation debriefing and do a better job of reflecting on our real patient care?
Short clinical debriefing –how?
Eppich and colleagues offer us a guide to how this might look in their article “Let’s talk about it”: translating lessons from healthcare simulation to clinical event debriefings and clinical coaching.1
They emphasise this is not about critical incident debriefings (which require different skills and approaches), but rather extending the concept of debriefing focused on performance gaps to potentially any clinical case or situation. They acknowledge the perceived and real barriers of limited time, variable skills, and nuanced relationships between ‘coach’ (who may be supervisor or peer or from another healthcare discipline) and providers being debriefed. A strength of the paper is the specific guidance on how to do this – the structure and phrases we might use when, for example, doing a 5 – 10 min short debrief after the initial phase of care for a trauma case in the ED.
Others have recognized this lack of habit and structure as a key barrier to learning conversations becoming embedded in our work. A UK group designed the TALK framework to “to guide structured team self-debriefing after unplanned learning events in clinical environments to promote a supportive culture of learning and patient safety in clinical settings”. The website provides very practical guidance and examples as to how to do this in 10 minutes or less.
One of the issues is that ‘debriefing gurus’ (and I realise most are way too humble to describe themselves this way, but others persist) are often associated with simulation centres or programs, and publish under academic banners. Translation is required. The clinical department leaders need to embrace the principle and practice of short clinical debriefing, and to underline the importance of performance improvement conversations by doing it themselves. Simulation experts can support that through contextualised faculty development.
We still need simulation (obviously 😊) as this offers different, complementary opportunities to improve individual, team and system performance.
Individual performance improvement – same principle?
I especially like the term ‘coaching conversations’ in the title of the Eppich paper, and prompts us to think even further about peer learning partnerships and more longitudinal habits of explicit reflection on performance. Experienced practitioners who completed their training some years ago will be familiar with the challenge of receiving useful feedback, or having a performance orientated discussion with colleagues.
My thoughts were influenced by a recent post on Supervision on the Don’t Forget the Bubbles (DFTB) blog. The author had recently experienced the specific meaning of that term in a mental health rotation, and illustrated how it supported a lifelong learning mindset and personal practice awareness that may be lacking in many of our work contexts. It reminded me of Atul Gawande’s New Yorker article on having a coach in the operating room. Perhaps we need to get more serious about having personal learning partnerships?
The next steps?
- Read the Eppich paper and check out the TALK website for a deep dive on making the most of your debriefing skills to have conversation focused on performance improvement
- Find a specific situation where this might work and be useful (e.g., I’m going to try this with our trauma cases just before we ‘stand down’)
- Work with a group invested in that specific clinical improvement issue, and those with skills and experience in the principles and conversational techniques for effective learning conversations.
- Develop (or adapt) a ‘script’ or structure for doing it (think about your RSI checklist…)
- Consider starting your own personal learning partnership
Interested in others thoughts and ideas?
- Walter J. Eppich, Paul C. Mullan, Marisa Brett-Fleegler, Adam Cheng, “Let’s Talk About It”: Translating Lessons From Health Care Simulation to Clinical Event Debriefings and Coaching Conversations, Clinical Pediatric Emergency Medicine, Volume 17, Issue 3, 2016, Pages 200-211, ISSN 1522-8401, http://dx.doi.org/10.1016/j.cpem.2016.07.001.
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