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

(n.d.). Retrieved from http://hospicefoundation.ie/wp-content/uploads/2013/04/End-of-Life-Care-Supporting-Staff-a-literature-review.pdfAbendorth. (2006). Predicting the risk of Compassion fatigue. Journal of Hospice and Palliative Nursing, 346-356.Alan, J. (2004). Essential Characteristics of Effective Balint Group Leadership. Family Medicine.Alkema, K. (2008). A study of the relationship between self care, compassion satisfaction and burnout among hospice professionals. Journal of social work in end of life and Palliative Care, 101-119.Aycock, N. (2009). Interventions to manage compassion fatigue in oncology nursing. Clinical Journal of Oncology Nursing, 183-191.Back, A. (2015). "Why Are We Doing This?" Clinician Helplessness in the Face of Suffering. Journal of Palliative Medicine, Vol. 18, No. 1.Balint Society Organization. (n.d.). Retrieved from http://americanbalintsociety.orgBarbour, L. Professional-Patient Boundaries in Palliative Care #172. Fast Facts and Concepts.

www.eperc.mcw.edu/fastfact/ff_172.htm

Beckman, H. (2015). The role of medical culture in the journey to resilience. Academic Medicine.Beresford, L. (2014). Stress, Burnout and Self Care Strategies for Hospice and Palliative Physicians. Retrieved from www.aahpm.org: www.aahpm.orgBoyle, D. (2006). Desperate Nursewives. Oncology Nursing Forum, 11.Boyle, D. (2011). Countering Compassion Fatigue: A Requisite Nursing Agenda. Online J Issues Nurs., (16)1.Bush, N. (2009). Compassion Fatigue: Are you at Risk? Oncology Nursing Forum, 24-28.

Fagin, C. (1983). Nursing as metaphor. New England Journal of Medicine, 116-117.Figley, C. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized.New York: Brunner/Mazel.Guillemin, M. (2015). Emotion, Narratives and Ethical Mindfulness. Academic Medicine.Hanna, D. (2007). Debriefing after a crisis. Nursing Management, 38-47.Hooper, C. (2010). Compassion satisfaction, burnout and compassion fatigue among emergency nurses compared with nurses in other selected inpatient specialties. Journal of emergency nursing, 420-427.Hough, C. L. (2005). Death Rounds: end of life discussions among medical residents in the intensive care unit. Journal of Critical Care, 20-25.Kanter, J. (2007). Compassion fatigue and secondary traumatization: A second look. Clinical Social Work Journal, 289-293.

Ebright, P. (2010). The complex work of RN's: Implications for health work environments. Online Journal of Issues in Nursing, 15(1).Erickson, R. (2007). Why emotions matter: Age, agitation, and burnout among registered nurses. Online Journal of Issues in Nursing, 13(1).

Chan, E. (2009). The use of interdisciplinary seminars for the development of caring dispositions in nursing and social work students. Journal of advanced Nursing, 2658-2667.Charles, S. (2013). The Wear-And-Tear of Daily Stressors on Mental Health. Psychol Sci, 733-741.Clay, A. (2007). Debriefing in the intensive care unit: a feedback tool to facilitate bedside teaching. Critical Care Medicine, 728-754.Coetzee, S. (2009). Compassion fatigue within nursing practice: A concept analysis. Nursing and Health Sciences, 235-243.

Katz, R. (2002). Our Patients, Our Families, Ourselves. American Behavioral Scientist, 327-339.Kearney, M. (2009). Self-care of Physicians Caring for Patients at the end of life: "Being Connected...a Key to My Survival". JAMA, 1155-1164.McCann, C. (2013). Resilience in the health professionals: A review of recent literature. International Journal of Wellbeing, 60-81.Mitchell, J. (n.d.). Critical Incident Stress Debriefing (CISD). Retrieved from www.info-trauma.org.Mullan, P. (2014). Educational Opportunities with Post event Debriefing. JAMA, 2333-2334.The Debrief Imperative. Murphy, J., Duke., W. 2011Neff, K. (2006). Self-compassion and adaptive psychological functioning. Journal of Res Pers, 139-154.Paolini, H. (2013). Antidotes to Burnout: Fostering Physician Resiliency, Well being and Holistic Development. Retrieved from Medscape: www.medscape.com/viewarticle/782514Peters, L. (2013). How death anxiety impacts Nurses caring for patients at the end of life: A review of the Literature. The Open Nursing Journal, 14-21.Potter, P. (2010). Compassion fatigue and burnout: Prevalence among oncology nurses. Clinical Journal of Oncology Nursing, E56-E62.Quinal, L. (2009). Secondary traumatization in oncology staff. Cancer Nursing, E1-E7.Sabo, B. (2006). Compassion fatigue and nursing work: Can we accurately capture the consequences of caring work? International Journal of Nursing Practice, 136-142.Sanchez-Reilly, S. (2012). Caring for oneself to care for others: physicians and their self care. Journal of Supportive Oncology.Sanders, S. (2012). Exploring Professional Boundaries in end of life care: Considerations for hospice social workers and other members of the team. Journal of social work at end of life and Palliative Care.

Stichler, J. (2009). Healthy, healthful and healing environments: A nursing imperative. Critical Care Nursing Quarterly, 176-188.Turner, A. (2004). A preliminary investigation between Balint and Non Balint Behavioral Medicine Training. Family Medicine.Urdang, E. (2010). Awareness of Self - A critical tool. Social Work Education, 523-538.Van Bogaert, P. (2009). Impact of Unit Level nurse practice environment and burnout on nurse-reported outcomes: a multilevel modeling approach. Journal of Clinical Nursing, 1644-1674.Walton, A. (2010). Imagine: Compassion fatigue training for nurses. Clinical Journal of Oncology Nursing, 399-400.Welsh, D. (1999). Care for the Caregiver: Strategies for avoiding "Compassion Fatigue". Clinical Journal of Oncology Nursing, 183-184.When Professionals Weep. Emotional and Countertransference Responses in end-of-life Care. R. Katz, T. Johnson

Sanso, N. (2015; Vol. 50, No 2). Palliative Care Professionals' Inner Life: Exploring the Relationships Among Awareness, Self Care, and Compassion Satisfaction and Fatigue, Burnout and Coping with Death. Journal of Pain and Symptom Management.Schantz, M. (2007). Compassion: A concept analysis. Nursing Forum, 48-55.Showalter, S. (2010). Compassion Fatigue: What is it? Why does it matter? Recognizing the symptoms, acknowledging the impact, developing the tools to prevent compassion fatigue and strengthen the professional already suffering from the effects. American Journal of Hospice and Palliative Medicine, 239-242.