Debriefing is a process of communication that takes place between a team following a clinical case; often the case would involve a major event such as cardiopulmonary arrest (CPA) (Gilmartin et al, 2020). This discussion between the team will be about specific case details and events that occurred, including discussion around the role and actions of each of those involved (Gilmartin et al, 2020).
There is little research in veterinary medicine into how debriefing may affect training and how it can impact staff, and those studies that do exist only briefly look at debriefing but are focused on other areas. However, when discussing the history of veterinary nursing, Ballantyne (2017) described many aspects of veterinary nursing as ‘echoing’ human research.
This review will look at debriefing, which different types of debriefing may be best ued in a veterinary hospital environment, how it may impact staff training, the development of individual skills, as well as mental wellbeing in veterinary medicine.
Training
The reassessment campaign on veterinary resuscitation (RECOVER) initiative discussed knowledge gaps in veterinary medicine and training, using question worksheets in veterinary emergency and general veterinary practice over a 3-month period (McMichael et al, 2012). McMichael et al's (2012) quantitative study analysed how to prepare staff for a cardiopulmonary arrest, suggesting that the performance of high-quality cardiopulmonary resuscitation (CPR) should be used in an attempt to improve survival. High-quality CPR is described as involving both cognitive performance of resuscitation as well as psychomotor skills, which are outlined as proper hand position, appropriate rate and depth as well as complete recoil of chest (McMichael et al, 2012). It was found that several studies have shown poor performance of these skills during basic and advanced CPR in the field (McMichael et al, 2012). McMichael et al (2012) discussed how debriefing can enhance high-quality CPR skills, and explained that debriefing results in no additional risk to the patient and can be an easy method for enabling preparedness and training (Andreatta et al, 2011). The Andreatta study showed an improvement in survival rates in 33–50% of human paediatric patients, with the use of simulation crash scenarios known as ‘mock codes’ and debriefing introduced into teaching programmes. A study by Wolfe discussed an improved survival rate, suggesting that debriefing can improve training as well as skill retention. It has also been argued that debriefing in health care can help improve skills and thereby decrease mortality in cardiac arrests (Wolfe et al, 2014). Wolfe et al's (2014) quantitative study looking at debriefing post CPR in human medicine included 120 patients needing chest compressions; the control group of 60 patients before debriefing had a survival rate to discharge of 33%. This increased to 52% in the group following interventional debriefing.
Hamilton (2005) reviewed the knowledge and skill retention of CPR training investigating skill loss in NHS nurses and looked at different training techniques, promoting debriefing after training and at how videotaping for debriefing post-simulation can be used to critically analyse a team's performance. It was concluded that video self-instruction has improved competence in resuscitation. Moser and Coleman (1992) found that skills decline more quickly than knowledge, declining as soon as 2 weeks post-training, and deteriorating to pre-training levels by 1–2 years later.
In a quantitative study on debriefing performed immediately after the event, known as ‘hot debriefing’, Gilmartin et al (2020) found that 100% of staff that took part in the study felt it had helped with their clinical practice. This suggests that debriefing can help with continued training.
The aforementioned studies have not reported any negative impacts of implementing debriefing, suggesting it is a tool that could be easily used in the veterinary environment (Figure 1). As discussed by Ballantyne (2017), historically veterinary nursing has often mimicked human nursing and this transferability from human to veterinary practise may support the transferability of debriefing to veterinary medicine.
Hot debriefing
Hot debriefing is a form of debriefing that happens immediately after a clinical event (Gilmartin et al, 2020). Gilmartin et al (2020) advocated implementing continuous development to cardiac arrest management using suggested improvements identified in the hot debriefings, such as ease of access to appropriate equipment as well as teamwork skills. The study suggested topics for the hot debriefing are pre-alert/handover, delegation, airway, circulation, communication, and documentation to create more structure. A positive outcome reported by Gilmartin et al (2020) was that recurrent issues with airway management, such as correct position and available equipment, as well as communication and scribing during a CPA, were addressed following debriefing through changes in the hospital procedure.
Gilmartin et al's (2020) study on hot debriefing was performed in one hospital's emergency department over 6 months and was implemented for 42% of all cardiac arrests. Results showed that 95% of participants felt the duration of the debrief was ‘just right’ (although no time was stated it is suggested these are brief) and 100% felt it helped their clinical practice. In acknowledgement of size and duration limitations of this initial study, and in the interest of gaining a better perspective into the outcome of hot debriefing and whether it is the best form of debriefing post CPR, Gilmartin et al (2020) are working on expanding the study to other areas of the same hospital as well as other emergency departments.
There is little published evidence indicating that hot debriefing has a positive or negative impact on veterinary patients requiring CPR. However, there is evidence that hot debriefing has a positive impact on staff in human medicine — 90% of participants felt that the hot debriefing helped their mental wellbeing (Gilmartin et at, 2020). Bhatnagar (2020) also discussed hot debriefing, and suggested it should be performed within hours of the event, and some of the discussion should focus on the immediate reactions and emotions of the team, suggesting that hot debriefing may help with staff mental wellbeing.
Cold debriefing
Bhatnagar (2020) described cold debriefing as a longer form of debriefing. This type of debriefing is termed ‘cold’ because it does not take place immediately after the event. In fact, some cold debriefings may take place weeks after the event and in this sense are similar to NHS morbidity and mortality meetings, which are often pre-arranged, for example every month (Sinitsky et al, 2019).
A quantitative study into cold debriefing by Wolfe et al (2020) performed over 2 years in paediatric resuscitations, looked at quality of chest compressions and medication delivery, as well as teamwork. Wolfe et al (2020) found that 88% of staff felt that the cold debriefing had improved resuscitation care. Results also showed that the debriefings identified areas that required improvement. For example, a total of 36 of the 93 debriefing forms (39%) showed a delay during resuscitation (Wolfe et al, 2020), suggesting that a cold debriefing to discuss this may prevent delays in starting CPR in the future by addressing the errors. It was also found that cold debriefings were used on a case-by-case basis, often choosing events with significant learning points.
Only 35% of sites involved in the study debriefed all events. Making time for cold debriefing was found to be an issue, with 20–25% reporting lack of time being one of the main barriers preventing cold debriefing, as well as financial support (20–25%) (Wolfe et al, 2020). Moreover, the data showed that physicians made up the majority of staff attending the cold debriefings, implying that nurses and respiratory therapists were unable or chose not to attend, despite all staff involved being invited to attend; this may suggest that compliance could also be a barrier in using debriefing. Although 88% of staff that participated in cold debriefing felt the cold debriefings had helped to improve resuscitation care (Wolfe et al, 2020), the study discussed that not all staff involved are able to attend. This could suggest that those not attending are not getting the benefits of a cold debriefing to potentially improve their CPR skills (Wolfe et al, 2020).
Mental wellbeing of staff
A review by Lloyd and Campion (2017) looking at occupational stress in veterinary nursing discussed how to improve resilience of staff. The study showed that although there is limited research into fatalities related to stress in veterinary nursing, there is evidence that veterinary surgeons have an increased suicide rate when compared with other professions (Lloyd and Campion, 2017). The review discussed burnout and compassion fatigue and researched different coping mechanisms. An example given by the authors as a coping mechanism is debriefing with other colleagues after an emotionally stressful event (Lloyd and Campion, 2017). Supporting this, another review into veterinary surgeons' suicide rate by Bartram and Baldwin (2010) found that although veterinarians had a lower number of suicides in comparison to other healthcare professions the proportional mortality rate was one of the highest. This supports the suggestion that in a profession with an increased suicide risk, anything that may be implemented to improve mental wellbeing should be done. This is reinforced by another study into veterinary suicides (Tomasi et al, 2019), which again showed a higher proportional mortality rate in veterinary professionals compared with the general public
Gilmartin et al (2020) showed that 90% of staff involved in hot debriefing felt it helped their mental wellbeing. This concurs with the suggestion by Lloyd and Campion (2017) that debriefing can be an important part of stress reduction, allowing stressful events to be appropriately analysed. A qualitive study in human medicine looking at nurses' experiences performing CPR was undertaken by Sjoberg et al (2015). The study looked at training, chaos and order during CPR as well as debriefing post cardiopulmonary resuscitation. Of those who were involved in the debriefing, several mentioned the importance of talking about difficult events, which helped them avoid taking home any adverse feelings (Sjorberg et al, 2015). This again agreed with both Gilmartin et al (2020) and Lloyd and Campion (2017) that debriefing can positively impact the mental wellbeing of staff.
None of the studies into debriefing showed evidence of a negative impact on staff mentally, to investigate this further broader research into the mental impact of debriefing should be performed. It is suggested that no one should leave work with unprocessed feelings, and lack of debriefing post-CPR can evoke negative feelings that can adversely affect staff (Makinen et al, 2007).
Conclusions
Reviewing the literature on both human-based and veterinary-based studies, the evidence shows that debriefing is often a positive tool in many aspects. Discussing the event of a CPA and the performance of CPR can have a positive impact on both patients and staff. The literature suggests that hot debriefings are optimal, taking place immediately, with the event and emotions fresh in staff members' minds, providing them with an outlet for those emotions and in turn helping their mental wellbeing. Cold debriefings, on the other hand, seem to be more difficult to organise and time manage.
Overall, there is little evidence in veterinary medicine to support the implementation of hot debriefings soon after any CPR event to use the debrief for both training as well as emotional wellbeing of staff involved. There is however evidence in the human medicine literature that shows that debriefing and specifically hot debriefing can be beneficial to staff training and wellbeing, this could suggest that it may positively impact veterinary medicine also. This is a topic in veterinary medicine that requires more research.
KEY POINTS
- Debriefing can play a key part in training and improving quality of cardiopulmonary resuscitation (CPR).
- Mental wellbeing can be positively impacted by debriefings.
- Cold debriefing showed an improvement to quality of chest compressions.
- Hot debriefing is optimum for staff attendance with the event fresh in mind.
- Further research into debriefing and CPR training is needed in veterinary medicine.