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Informal debriefing: Underutilization in critical care settings.

The art and science of nursing cannot be learned from text books or in a classroom alone. As adult learners, registered nurses bridge the theory-practice gap while providing nursing care within the clinical area by reflecting on the experience, and adapting or reinforcing their behaviour (Kolb, 1984). Debriefing is an essential component towards achieving professional improvement and development (Boerboom, Stalmeijer, Dolmans, & Jaarsma, 2015; Corbett, Hurko, & Vallee, 2012; Kemp & Baker, 2013). A way to facilitate this is for peers to provide feedback on application of skills or thinking through informal debriefing either during, following, or shortly after a clinical situation presents itself. If provided in a nurturing positive manner, attitudes or techniques can be reinforced or adapted towards achieving clinical competence. Based on personal experience of working in specialized critical care settings this seems to occur coincidentally based on being employed within a positive supportive environment. There needs to be an increased awareness and recognition of the positive value of providing informal debriefing within the clinical setting so that the professional and personal development of bedside clinicians is not left to chance. In this article, the author presents a discussion based on personal experiences and observations regarding the importance of informal debriefing among work colleagues in the critical care setting. Consideration will be provided as to why informal debriefing appears to be underused, and suggestions for possible solutions that can be incorporated in the work setting will be discussed.

Background

Experiential learning has long been recognized as a means of applying theory into practice, especially for adult learners. Kolb (1984) suggests that learning is an evolving action based on the process rather than the end result. It could be said that learning is never completely achieved, as initial theory is applied but then adapted to unique situations based on previous experience. Schon (1983) identified this process as personal reflection on acquired knowledge or observation, conceptualizing how it can be applied into practice, and then experimenting and adapting this new knowledge. Debriefing following application of learning into practice can ensure enhancement of new or ongoing learning by providing essential feedback. Analysis of a thought process that contributes to a clinical adaptation supports the development of critical thinking (Maestre & Rudolph, 2015). Therefore, the evolving process of learning and professional development continues, as a progression towards competent, proficient and safe practice throughout a nurse's career (Benner, 1984).

Many opportunities for learning do not present in isolation with a fixed beginning and end, as in simulation scenarios. Bedside nurses often find themselves in continuous states of learning, experimenting and adapting, as part of their daily nursing role. Patients do not always follow predictable disease or behavioural patterns and this is especially evident in critical care settings. Bedside critical care nurses have to continuously draw on previous knowledge and experience to apply to their patient care by which to anticipate possible developments or complications. In such situations there is often no definite opportunity when debriefing can take place. Invaluable respectful informal feedback between members of the multidisciplinary team provides a supportive learning environment and encourages the sharing of ideas or suggestions towards a common outcome (Hall, Brajtman, Weaver, Grassau, & Varpio, 2014). This, in turn, contributes toward enhanced clinical practice (Muldowney & McKee, 2011).

Definitions of debriefing

Debriefing is the process of reviewing situations, exploring thoughts, and questioning assumptions by which to achieve positive learning based on lived experiences (Dreifuerst, 2015). Constructive feedback can be provided as part of a simulation exercise or following a critical incident to review the application of knowledge into practice (Cantrell, 2008). Performance can be revisited to allow deeper understanding, encourage critical thinking, and adjust behaviours towards future clinical situations (Cant & Cooper, 2011; Dreifuerst, 2015; Fey, 2014).

There are a number of approaches to providing feedback within clinical settings that lend themselves to different learning opportunities. Structured or unstructured, facilitated or informal, oral or written, and group or individual formats are all valid depending on the learning situation or setting (Dufrene & Young, 2014). While it is important that debriefing occurs to ensure learning outcomes, the presentation and timing determine the beneficial effects on future clinical practice and critical thinking (Cantrell, 2008; Willard, 2014).

The most recognized form of debriefing is planned, facilitated sessions led by an instructor immediately or shortly after a learning opportunity has occurred. This allows discussion related to actions, thoughts, and feelings that contributed to the situation while still fresh in the minds of those involved (Dufrene & Young, 2014; Stocker, Burmester, & Allen, 2014). Some facilitators prefer to apply some form of structure to these sessions, although this may be based on their own comfort level in providing debriefing or the clinical situation (Cant & Cooper, 2008; Wickers, 2010). Some debriefing may require documentation, especially in the case of student evaluations or performance reviews (Corbett et al., 2012). Ultimately, debriefing should be flexible to allow learners to explore their thoughts; the emphasis is on achieving a safe, non-judgemental and confidential forum that is adaptable to the needs of those receiving debriefing (Corbett et al., 2012; Lavoie, Pepin, & Boyer, 2013; Maestre & Rudolph, 2015).

The challenge of providing debriefing is to promote the gaining of experience and clinical competence. Informal debriefing is recognized as providing spontaneous feedback either during or after critical learning situations, not formally observed and often within general conversation among peers. Crookall (2010) recognized the importance of informal debriefing within the computer gaming world, but warned against mistaking it as generalized discussion and losing the full benefits of feedback. Even so, valuable learning and development of competencies can be achieved where time and resources are limited and patient conditions are unstable. Initial feedback can be provided through a brief encounter during a critical incident, while carrying out a procedure or during handover at shift change. Further discussion can then be carried out during the remainder of the shift, on subsequent shifts or by other support methods, such as through social media.

Literature search

A search of CINAHL, ProQuest and Google Scholar electronic databases using the key words "informal debriefing" produced more than 600 articles between the years 2006 and 2016 from nursing, education, counselling, and medicine. The nursing articles referred to debriefing as an important means of providing constructive feedback towards achieving essential learning outcomes, mainly focusing on student or simulation teaching situations within controlled learning environments (Cantrell, 2008; Corbett et al., 2012; Dreifuerst, 2015; Dufrene & Young, 2014; Fey, 2014; Kemp & Baker, 2013; Maestrea & Rudolph, 2015; Suwanbamrung, 2015; Wickers, 2010). This reflects the increased use of simulation within nursing education to achieve baseline clinical competencies in a safe and controlled setting (Dufrene & Young, 2014; Wickers, 2010). Debriefing in these situations referred to planned, controlled scenarios with a fixed beginning and end where aspects of learning can be reflected on before applying to subsequent practice.

Narrowing the search to include the key words "clinical settings" significantly reduced the number of articles where the use of informal debriefing referred to critical incident reviews or team evaluations (Dufrene & Young, 2014). Informal debriefing was considered to facilitate learning from actual situations towards achieving competency or providing support following traumatic situations in emergency, pediatric or intensive care units (Corbett et al., 2012; Healy & Tyrrell, 2013; Maloney, 2012; Smith, Wasilowsky, & Valeriano, 2012).

There was a lack of relevant articles related to the value of informal debriefing in clinical settings outside the realms of student nurses or simulation situations. Muldowney and McKee (2011) acknowledged the developmental needs of novice intensive care nurses and how clinical support creates a positive learning environment. However, they do not mention debriefing as a means of fulfilling these needs (Muldowney & McKee, 2011). Brindise, Phophairat Baker, and Juarez (2015) recognized the need for frequent documented debriefing for novice critical care nurses, as a means of support beyond an initial orientation period.

The importance of informal debriefing

Clinical settings

All registered nurses are responsible for continuing their professional development to ensure provision of current and evidence-based patient care (Canadian Nurses Association,

2016). As adult learners, registered nurses apply knowledge in their clinical setting where it is practised and adapted until a level of comfort is achieved and maintained (Kolb, 1984). Schon (1983) advocated that only through reflection on each situation can behaviours be reinforced or changed and true learning outcomes achieved. This supports the premise that self-reflection supplemented by informal peer feedback can further enhance learning and individual progress (Kolb, 1984; Schon, 1983).

On completion of a course, registered nurses return to practise as novice practitioners from the perspective of that body of new knowledge, but also bring a wealth of previously acquired skills and experience on which to base continuing progress. Benner (1984) noted how nurses gain valuable practical opportunities to test and apply skills with theory that takes them along a continuum towards becoming competent, proficient expert clinicians. This process does not happen in isolation; informal discussions with peers and leaders provide opportunities for rich conversations to promote critical thinking. Collaboration among colleagues towards supporting each other is a two-directional process; nurses working within a nurturing environment benefit from continuously striving to improve their practice towards providing competent nursing care (Muldowney & McKee, 2011).

Critical care settings

The emphasis to continuously develop and improve nursing practice is strongly evident in critical care settings. Patients admitted in the acute stages of complicated clinical presentations often do not fall within predictable parameters or follow definite progressions. Reflections on previous experience and application of new knowledge are drawn on and adapted to each situation. Valuable collaborative learning occurs through informal debriefing "in the moment" as each critical care nurse contributes his/her own experience, knowledge and expertise to a patient case while exploring or supporting each other's practice. Ongoing discussions either immediately after or at a safer point of time consolidate the acquired learning for future use.

Many critical care nurses are required to complete a specialized course or program prior to working in a critical care setting. These courses/programs usually involve a mix of classroom and clinical shifts over three to six months. It is unrealistic to expect that new learning can be fully achieved on completion of a course/program and subsequent orientation period. These nurses often enter the program as experienced nurses from their previous setting, which can contribute towards stress and anxiety, which may, ultimately, affect performance and socialization into the critical care setting (Muldowney & McKee, 2011). In the case of novice critical care nurses, it is important that mentoring continues beyond the initial orientation period and safe exposure to new clinical situations is provided. An example that comes to mind is that of a critical care nurse who had completed three supervised femoral sheath removals, as part of her initial orientation, however, had not had opportunity to continue practising this skill. Some weeks later she was assigned a patient who required this procedure, yet she felt able to approach another critical care nurse working nearby to verify her intended actions and to request assistance if she were to need it. Ongoing informal support and debriefing is essential to ensure that these advanced beginners are given ample opportunities to consolidate new learning while drawing on relevant previous experience (Muldowney & McKee, 2011).

Another important consideration is the recruitment of critical care nurses from other locations or overseas. Their knowledge and level of competency may be high, but require support as they acclimatize to the culture of the unit, different healthcare system or new country (Neiterman & Bourgeault, 2015).

Flexibility in the approach to debriefing is important while respecting the level of expertise that these new recruits bring to the setting. In some cases, the established critical care nurses learn as much from these new team members through informal discussions, sharing of stories and offering feedback.

Underutilization of informal debriefing

Culture of the unit

The culture of a unit can determine accepted behaviours among nursing staff and some specialty units gain reputations for "eating their young" due to a negative nurturing environment. Although support for individuals to gain competence and confidence comes from within nursing teams, the attitudes of leaders are often reflected throughout the unit (Daft, 2015). If providing supportive debriefing is not considered important by senior staff members or leadership, then junior or new nurses follow suit in an attempt to fit in and be accepted. This can contribute to low morale and high staff turnover resulting in instability that is not conducive with establishing positive working environments (Dawson, Stasa, Roche, Homer, & Duffield, 2014).

Lack of knowledge on how to use debriefing

Some nurses may not have received any formal instruction on how to effectively provide debriefing or constructive peer feedback. A reluctance to provide feedback is further exacerbated if nurses do not observe debriefing being actively offered in their clinical setting. Subconsciously this sends a message that supporting staff through constructive feedback is not recognized as being high priority, important, or relevant.

Lack of confidence to provide debriefing

Some hospitals provide workshops for staff on how to effectively provide feedback. However, nurses may lack confidence in offering support due to insufficient practice. Staff may also have had a bad experience of giving or receiving debriefing in the past, therefore, fear repeating the same mistake. Bedside nurses might not want to risk upsetting a work colleague whom they must continue working alongside; this might create an awkward relationship. Unfortunately, this could result in nurses who are struggling and not receiving the encouragement and support they so badly need to gain confidence in their practice and provide safe patient care.

Overcoming barriers and challenges

Approaching staff within clinical settings and identifying what prevents them from providing valuable debriefing would allow those specific issues to be addressed and overcome. In many cases, keeping open respectful communication forms part of the solution to overcoming apparent barriers and challenges (Daft, 2015). Increasing awareness of the value of debriefing, encouraging change champions to model expected behaviours, and gaining support of leadership can contribute towards establishing a nurturing culture for all levels of nurses (Muldowney & McKee, 2011; Ploeg et al., 2010).

Education

Nurses who have not received formal instruction on providing debriefing should be offered education. Ideally this should be unit-based, thereby allowing socialization within the group while learning to apply new knowledge and skills. Emphasis needs to be placed on positive aspects of providing constructive, non-judgemental, informal feedback towards personal and professional development, as an integral part of their nursing role (Dreifuerst, 2015). Active teaching strategies such as the use of brainstorming or role play can encourage interactive and contextual learning (Stevens, 2015). In addition, there needs to be opportunity for essential ongoing practice within the clinical setting whereby debriefers also receive feedback and encouragement, as they gain confidence in providing such important support.

Practical models of debriefing. To be successful, the concept of providing informal debriefing needs to be presented in the form of adaptable tools that can be easily incorporated into daily practice. There are a number of debriefing models within nursing, education and aviation that follow linear or cyclical processes (Dreifuerst, 2010; Fey, 2014; Lavoie et al., 2013; Zigmont, Kappus, & Sudikoff, 2011). Some models are complex, which makes them challenging to adapt into a practical setting. The key to the debriefing process is allowing learners to explore their own underlying thoughts towards enhanced reasoning (Raymond & Usherwood, 2013). Dreifuerst (2010) developed the Debriefing for Meaningful Learning[C] model, which encourages reflection on what went well, what did not go well, and how one might approach the problem differently in the future while considering six stages of reflection (Dreifuerst, 2010, 2015). The 3D Model of Debriefing[C] also uses open questions that guide the discussion through three stages of dissemination, discovery and understanding, which may be more user friendly due to its shorter process (Zigmont et al., 2011). The key to any debriefing is to allow learners to explore their own underlying thoughts toward enhanced reasoning (Raymond & Usherwood, 2013). When applied through informal discussion with peers, debriefing is more effective and subsequent critical thinking can be drawn on for future clinical situations (Dreifuerst, 2015; Maestre & Rudolph, 2015; Zigmont et al., 2011).

Orientation

Having introduced informal debriefing, it is important to maintain momentum and establish the provision of constructive debriefing as an expectation of all nursing staff. New staff to the unit should be introduced to the concept as part of their unit orientation. Existing staff need to be provided encouragement and ongoing support to incorporate debriefing as part of their daily practice, especially if they are responsible for mentoring new or novice staff.

The use of role model champions helps to reinforce practice changes such as creating a supportive clinical environment; champions based at bedside level are able to effectively influence and sustain changes in behaviour (Ploeg et al., 2010). When a small group of nurses is seen demonstrating informal debriefing and successfully integrating it into their regular nursing practice this will encourage others to feel less intimidated and follow their example.

Unit culture

Providing staff with the education and tools to carry out effective debriefing on an informal non-judgemental basis contributes towards establishing a supportive and nurturing culture within the clinical setting. Further demonstration of commitment to this culture needs to be visible from the leadership team to ensure bedside nurses feel valued (Kunzle, Kolbe, & Grote, 2010). In the case of novice critical care nurses, the charge nurse and nurse educator should be aware of possible learning opportunities and assign them to appropriate patients, with support from an experienced nurse. Adequate staffing levels and skill mix allow new experiences to be accommodated and learning to be consolidated through ongoing guidance and feedback. This reinforces the philosophy that supporting professional and personal development of staff is given high priority and an expected behaviour by the leadership team.

Overcoming resistance and establishing change takes time, energy, and persistence while being dependent on individual and organizational readiness (Rafferty, Jimmieson, & Armenakise, 2012). Focusing on the positive aspects of creating a nurturing learning environment for all bedside staff can help achieve such worthwhile goals.

Summary

Despite an abundance of literature regarding the benefits of debriefing, there is limited research on the value of informal debriefing within the clinical setting. This suggests the need for further study to support the importance of providing constructive peer feedback towards personal and professional development.

In the unpredictable clinical setting the value of debriefing often seems to be overlooked because it might be seen as time consuming or creating animosity among staff. Such barriers to providing informal debriefing could be overcome by ensuring staff are knowledgeable and comfortable in soliciting and giving constructive feedback within their daily nursing practice, and awareness by leadership to facilitate safe exposure to new clinical situations. By embracing the nurturing of all levels of staff these approaches may contribute to a positive supportive clinical environment.

Julie Werry, MN, RN, CCN(C), Cardiac Critical Care RN, Cardiac Intensive Care Unit, St. Pauls Hospital, Vancouver, BC.

Address for correspondence: Julie Werry, CICU, St. Pauls Hospital, 1081 Burrard Street, Vancouver, BC V6Z 1Y6

Email: jwerry@providencehealth.bc.ca

Phone: +1 604 682 2344 local 62285

Acknowledgements

The author would like to thank Dr. Rosemary Kohr of Athabasca University for editing earlier drafts of this manuscript.

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By Julie Werry, MN, RN, CCN(C)
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Publication:The Canadian Journal of Critical Care Nursing
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Date:Dec 22, 2016
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