"A debriefer must be neutral" and other debriefing myths: a systemic inquiry-based qualitative study of taken-for-granted beliefs about clinical post-event debriefing

BACKGROUND

The goal of this study was to identify taken-for-granted beliefs and assumptions about use, costs, and facilitation of post-event debriefing. These myths prevent the ubiquitous uptake of post-event debriefing in clinical units, and therefore the identification of process, teamwork, and latent safety threats that lead to medical error. By naming these false barriers and assumptions, the authors believe that clinical event debriefing can be implemented more broadly.

METHODS

We interviewed an international sample of 37 clinicians, educators, scholars, researchers, and healthcare administrators from hospitals, universities, and healthcare organizations in Western Europe and the USA, who had a broad range of debriefing experience. We adopted a systemic-constructivist approach that aimed at exploring in-depth assumptions about debriefing beyond obvious constraints such as time and logistics and focused on interpersonal relationships within organizations. Using circular questions, we intended to uncover new and tacit knowledge about barriers and facilitators of regular clinical debriefings. All interviews were transcribed and analyzed following a comprehensive process of inductive open coding.

RESULTS

In total, 1508.62 min of interviews (25 h, 9 min, and 2 s) were analyzed, and 1591 answers were categorized. Many implicit debriefing theories reflected current scientific evidence, particularly with respect to debriefing value and topics, the complexity and difficulty of facilitation, the importance of structuring the debriefing and engaging in reflective practice to advance debriefing skills. We also identified four debriefing myths which may prevent post-event debriefing from being implemented in clinical units.

CONCLUSION

The debriefing myths include (1) debriefing only when disaster strikes, (2) debriefing is a luxury, (3) senior clinicians should determine debriefing content, and (4) debriefers must be neutral and nonjudgmental. These myths offer valuable insights into why current debriefing practices are ad hoc and not embedded into daily unit practices. They may help ignite a renewed momentum into the implementation of post-event debriefing in clinical settings.

A practical guide to virtual debriefings: communities of inquiry perspective

Many simulation programs have recently shifted towards providing remote simulations with virtual debriefings. Virtual debriefings involve educators facilitating conversations through web-based videoconferencing platforms. Facilitating debriefings through a computer interface introduces a unique set of challenges. Educators require practical guidance to support meaningful virtual learning in the transition from in-person to virtual debriefings. The communities of inquiry conceptual framework offer a useful structure to organize practical guidance for conducting virtual debriefings. The communities of inquiry framework describe the three key elements-social presence, teaching presence, and cognitive presence-all of which contribute to the overall learning experience. In this paper, we (1) define the CoI framework and describe its three core elements, (2) highlight how virtual debriefings align with CoI, (3) anticipate barriers to effective virtual debriefings, and (4) share practical strategies to overcome these hurdles.

Nurses’ voice: the role of hierarchy and leadership

Purpose

Voicing concerns and suggestions is crucial for preventing medical errors and improving patient safety. Research suggests that hierarchy in health-care teams impair open communication. Hierarchy, however, can vary with changing team composition, particularly during acute care situations where more senior persons join the team later on. The purpose of this study is to investigate how changes in hierarchy and leadership were associated with nurses’ voice frequency and nurses’ time to voice during simulated acute care situations.

Design/methodology/approach

This study’s sample consisted of 78 health-care providers (i.e. nurses, residents and consultants) who worked in 39 teams performing complex clinical scenarios in the context of interprofessional, simulation-based team training. Scenarios were videotaped and communication behaviour was coded using a systematic coding scheme. To test the hypotheses, multilevel regression analyses were conducted.

Findings

Hierarchy and leadership had no significant effect on nurses’ voice frequency. However, there were significant relationships between nurses’ time to voice and both hierarchy (γ = 30.00, p = 0.002; 95 per cent confidence interval [CI] = 12.43; 47.92) as well as leadership (γ = 0.30, p = 0.001; 95 per cent CI = 0.12; 0.47). These findings indicate that when more physicians are present and leadership is more centralised, more time passes until the first nurses’ voice occurred.

Originality/value

This study specifies previous findings on the relationships between hierarchy, leadership and nurses’ voice. Our findings suggest that stronger hierarchy and more centralised leadership delay nurses’ voice but do not affect the overall frequency of voice.

Self- and interdiffusion in dilute liquid germanium-based alloys

Self- and inter-diffusion coefficients in liquid Ge and dilute Ge-based Ge-Si, Ge-Au, Ge-In, Ge-Ce and Ge-Gd alloys-containing 2 at% additions, respectively, are measured using a comprehensive approach of measuring techniques: quasi-elastic neutron scattering, in situ long-capillary experiments combined with x-ray radiography, and a long-capillary experiment under microgravity conditions. Resulting inter- and Ge self-diffusion coefficients are equal within error bars for each investigated alloy. The interdiffusion coefficients are smaller for the alloys containing Ce and Gd, However, no dependence of the atomic mass of the minor additions, that varies by about a factor of seven between Si and Au, on the diffusion coefficients could be observed. This demonstrates that in a loosely-packed metallic liquid with fast diffusive dynamics the diffusion mechanism is highly collective in nature.

Managing psychological safety in debriefings: a dynamic balancing act

Debriefings should promote reflection and help learners make sense of events. Threats to psychological safety can undermine reflective learning conversations and may inhibit transfer of key lessons from simulated cases to the general patient care context. Therefore, effective debriefings require high degrees of psychological safety—the perception that it is safe to take interpersonal risks and that one will not be embarrassed, rejected or otherwise punished for speaking their mind, not knowing or asking questions. The role of introductions, learning contracts and prebriefing in establishing psychological safety is well described in the literature. How to maintain psychological safety, while also being able to identify and restore psychological safety during debriefings, is less well understood. This review has several aims. First, we provide a detailed definition of psychological safety and justify its importance for debriefings. Second, we recommend specific strategies debriefers can use throughout the debriefing to build and maintain psychological safety. We base these recommendations on a literature review and on our own experiences as simulation educators. Third, we examine how debriefers might actively address perceived breaches to restore psychological safety. Re-establishing psychological safety after temporary threats or breaches can seem particularly daunting. To demystify this process, we invoke the metaphor of a ‘safe container’ for learning; a space where learners can feel secure enough to work at the edge of expertise without threat of humiliation. We conclude with a discussion of limitations and implications, particularly with respect to faculty development.

Laborious but Elaborate: The Benefits of Really Studying Team Dynamics

In this manuscript we discuss the consequences of methodological choices when studying team processes "in the wild." We chose teams in healthcare as the application because teamwork cannot only save lives but the processes constituting effective teamwork in healthcare are prototypical for teamwork as they range from decision-making (e.g., in multidisciplinary decision-making boards in cancer care) to leadership and coordination (e.g., in fast-paced, acute-care settings in trauma, surgery and anesthesia) to reflection and learning (e.g., in post-event clinical debriefings). We draw upon recently emphasized critique that much empirical team research has focused on describing team states rather than investigating how team processes dynamically unfurl over time and how these dynamics predict team outcomes. This focus on statics instead of dynamics limits the gain of applicable knowledge on team functioning in organizations. We first describe three examples from healthcare that reflect the importance, scope, and challenges of teamwork: multidisciplinary decision-making boards, fast-paced, acute care settings, and post-event clinical team debriefings. Second, we put the methodological approaches of how teamwork in these representative examples has mostly been studied centerstage (i.e., using mainly surveys, database reviews, and rating tools) and highlight how the resulting findings provide only limited insights into the actual team processes and the quality thereof, leaving little room for identifying and targeting success factors. Third, we discuss how methodical approaches that take dynamics into account (i.e., event- and time-based behavior observation and micro-level coding, social sensor-based measurement) would contribute to the science of teams by providing actionable knowledge about interaction processes of successful teamwork.

Transverse resonance island buckets for synchrotron-radiation based electron time-of-flight spectroscopy

At the Metrology Light Source (MLS), the compact electron storage ring of the Physikalisch-Technische Bundesanstalt (PTB) with a circumference of 48 m, a specific operation mode with two stable closed orbits for stored electrons was realized by transverse resonance island buckets. One of these orbits is closing only after three turns. In combination with single-bunch operation, the new mode was applied for electron time-of-flight spectroscopy with an interval of the synchrotron radiation pulses which is three times the revolution period at the MLS of 160 ns. The achievement is of significant importance for PTB's future programs of angular-resolved electron spectroscopy with synchrotron radiation and similar projects at other compact electron storage rings. The scheme applied here for selecting the photons originating from a particular orbit by optical imaging has been used before in fs slicing applications and may be relevant for the BESSY VSR project of the Helmholtz-Zentrum Berlin.

The dual nature of adaptive coordination in teams

Adaptive team coordination is a central topic in the team dynamics literature. Most team adaptation research to date addresses team responses to demands for flexibility triggered by dynamic external forces. Little explicit attention has been paid to demands for stability created by continued pressures on efficiency and control. To capture this dual nature of adaptive coordination, we propose to characterize adaptation triggers in terms of stability and flexibility demands and suggest four modes of adaptive coordination that enable teams to adequately balance these demands. Grounded in team as well as organizational literatures, we explicate the specific patterns of coordination mechanisms comprising each mode of coordination, termed experiential, exploitative, exploratory, and ambidextrous coordination. The new insights offered into team adaptive coordination can spur research that further integrates team and organizational perspectives on adaptation processes.

Using educational video to enhance protocol adherence for medical procedures

BACKGROUND

Better education of clinicians is expected to enhance patient safety. An important component of education is adherence to standard protocols, which are mainly available in written form. Believing in the potential power of videos, we hypothesized that the introduction of an educational video, based on an institutional standard protocol, would foster adherence to the protocol.

METHODS

We conducted a prospective intervention study of 425 anaesthesia procedures and teams (202 pre-video and 223 post-video) involving 1091 team members (516 pre-video and 575 post-video) in seven individual operating areas (with a total of 30 operating rooms) in a university hospital. Failure of adherence to safety-critical tasks during rapid sequence anaesthesia inductions was assessed during systematic on-site observations pre- and post-introduction of an educational video demonstrating evidence-based and best practice guidelines.

RESULTS

The odds for failure of adherence to safety-critical tasks between the pre- and post-intervention period were reduced, odds ratio 0.34 (95% confidence interval 0.27-0.42, P<0.001). The risk for failure of adherence was reduced significantly for eight of the 14 safety-critical tasks (all P<0.001).

CONCLUSIONS

This study provides empirical evidence for the effectiveness of an educational video to enhance adherence to a standard protocol during complex medical procedures. The introduction of a video can reduce failure of adherence to safety-critical tasks and contribute to patient safety. We recommend the introduction of videos to improve protocol adherence.

Twelve tips for integrating team reflexivity into your simulation-based team training

Due to increasing complexity in healthcare, clinicians must often make decisions under uncertain conditions in which teams must be flexible and process emerging information "on the fly" in order to adapt to changing circumstances. A crucial strategy that helps teams to adapt, learn, and develop is team reflexivity (TR) - a team's ability to collectively reflect on group objectives, strategies, processes, and outcomes of past and current performance and to adapt accordingly. We provide 12 evidence-based tips on incorporating TR into simulation-based team training (SBTT). The first three points elaborate on basic principles of TR, when TR can take place and why it matters. The following nine tips are then organized according to three phases in which teams are able to engage in TR: pre-action, in-action, and post-action. SBTT represents an ideal venue to train various TR behaviors that foster team learning and improve patient care.

[Comparison of two models of a treatment area with respect to treatment times in critically ill patients : A pilot study]

BACKGROUND

In the case of a mass casualty incident an advanced medical post (AMP) plays a central role in the medical care by ambulance service and civil protection units. Besides the traditional organization with one triage category per medical services tent, it can also be structured in a mixed form (i.e. a defined number of patients with different triage categories are assigned to each medical services tent). To date it remains unclear which organization format is better in order to rapidly evacuate those patients with the highest priority.

METHODS

The Medical Task Force of Lower Franconia treated 50 identical and standardized training patients including 18 triage category red/emergency (36%), 12 triage category yellow/urgent (24%), 18 triage category green/non-urgent (36%) and 2 triage category black/dead (4%) in the course of a scheduled field exercise within two consecutive training sessions (first session: classical structure, second session: mixed structure). The training patients were represented by a dynamic patient simulation, whereby simulation cards showed injury patterns and the external appearance of the patients at a defined point which required certain interventions. The patients' conditions changed when these measures were accomplished or neglected. The length of stay of the patients with the triage category red/emergency at the AMP (start of triage to start evacuation) as well as the overall number of evacuated patients were collated and compared.

RESULTS

Out of 18 patients with the triage category red/emergency, 13 patients in each session were evacuated in one pass. During the first session the mean evacuation time at the AMP was 25 min and during the second session the mean evacuation time was 18 min. After the end of the 90 min of exercise time in the first session 14 non-critical patients (triage categories yellow/urgent and green/non-urgent, n = 30) were still left at the AMP (16 evacuated) and in the second session 12 (18 evacuated).

CONCLUSION

Depending on the mission requirements the mixed form of AMP organization can provide several advantages. In addition to rapid operational readiness and high flexibility the patient distribution by triage category could be processed better and the evacuation time of critical patients could be shortened.

Nucleation study for an undercooled melt of intermetallic NiZr

Electrostatic levitation is applied in order to undercool liquid glass forming NiZr significantly below its melting temperature. For NiZr large undercoolings are found to be highly reproducible with this experimental method. One single NiZr sample of high purity is undercooled 200 consecutive times which leads to a distribution function of undercooling temperatures. Within a statistical approach of classical nucleation theory, the undercooling distribution is analyzed yielding parameters, e.g., a pre-exponential factor of K_V ≈ 10³⁵ m^-3 s^-1, which indicates homogeneous nucleation. This result is consistent with the crystallization behavior of NiZr at high undercooling and with the corresponding microstructural analysis. Since NiZr is a representative of the very common CrB structure type, with 132 isostructural phases existing, understanding its nucleation behavior adds important knowledge to the nucleation of binary alloys in general.

What’s the headline on your mind right now? How reflection guides simulation-based faculty development in a master class

Introduction

The demand for highly skilled simulation-based healthcare educators (SBEs) is growing. SBEs charged with developing other SBEs need to be able to model and conduct high-quality feedback conversations and ‘debrief the debriefing’. Direct, non-threatening feedback is one of the strongest predictors of improved performance in health professions education. However, it is a difficult skill to develop. Developing SBEs who can coach and support other SBEs is an important part of the faculty development pipeline. Yet we know little about how they get better at skilled feedback and the ability to reflect on it. There is scant evidence about their thoughts, feelings and dilemmas about this advanced learning process. To address this gap, we examined advanced SBE’s subjective experience as they grappled with challenges in a 4-day advanced SBE course. Their reflections will help target faculty development efforts.

Methods

Using a repeated, identical free-writing task, we asked “What is the headline for what is on your mind right now?”

Results

A five-theme mosaic of self-guiding reflections emerged: (1) metacognitions about one’s learning process, (2) evaluations of sessions or tools, (3) notes to self, (4) anticipations of applying the new skills in the future, and (5) tolerating the tension between pleasant and unpleasant emotions.

Conclusions

The results extend simulation-based education science by advocating the motivational role of noting inconsistencies between one’s intention and impact and the central role of self-regulation, emotion, and experiencing feedback and debriefing from multiple perspectives for improving advanced skills of SBEs. Recommendations for faculty development are discussed.

Differences in talking-to-the-room behaviour between novice and expert teams during simulated paediatric resuscitation: a quasi-experimental study

Background

Team coordination represents an important factor for clinical performance. Research in this area suggests that not only behaviour frequencies but also patterns of team coordination constitute a central aspect of teamwork. However, little is known about potential differences in coordination patterns between novice teams (ie, teams of inexperienced members) and expert teams (ie, teams of experienced members). The current study addresses this gap by investigating the use of talking-to-the-room—an important implicit coordination behaviour—in novice teams versus expert teams.

Aim

To illustrate differences in coordination behaviour between novice and expert teams. This will provide important knowledge for simulation-based training.

Methods

The study was conducted in the context of two resuscitation training courses (introductory course and refresher course) for staff members at a children’s hospital. Volunteers from both courses participated in the study. They were randomly assigned to 16 teams each consisting of one physician and two nurses. The study used a quasi-experimental design with two conditions (novice vs expert). Participants of the introductory course were assigned to the novice condition (eight teams), and participants of the refresher course were assigned to the expert condition (eight teams). All teams completed the same standardised paediatric resuscitation scenario. They were videotaped during the simulation, and team coordination behaviour was coded using Co-ACT.

Results

Lag-sequential analysis of 1902 distinct coordination acts revealed that novice teams and expert teams differed significantly in their coordination behaviour. Expert teams were characterised by patterns in which implicit coordination behaviour (ie, talking to the room) was followed by further implicit coordination behaviour and not followed by explicit coordination behaviour (ie, instructions), whereas the reverse was found for novice teams.

Conclusion

The current study highlights role of coordination patterns for understanding teamwork in healthcare and provides important insights for team training.

How to debrief teamwork interactions: using circular questions to explore and change team interaction patterns

We submit that interaction patterns within healthcare teams should be more comprehensively explored during debriefings in simulation-based training because of their importance for clinical performance. We describe how circular questions can be used for that purpose. Circular questions are based on social constructivism. They include a variety of systemic interviewing methods. The goals of circular questions are to explore the mutual dependency of team members’ behavior and recurrent behavior patterns, to generate information, to foster perspective taking, to “fluidize” problems, and to put actions into relational contexts. We describe the nature of circular questions, the benefits they offer, and ways of applying them during debriefings.

SafAIRway: an airway training for pulmonologists performing a flexible bronchoscopy with nonanesthesiologist administered propofol sedation: A prospective evaluation

Nonanesthesiologist administered propofol (NAAP) sedation for flexible bronchoscopy is controversial, because there is no established airway management (AM) training for pulmonologists. The aim was to investigate the performance and acceptance of a proposed AM algorithm and training for pulmonologists performing NAAP sedation. The algorithm includes using 3 maneuvers including bag mask ventilation (BMV), laryngeal tube (LT), and needle cricothyrotomy (NCT). During training (consisting of 2 sessions with a break of 9 weeks in between), these maneuvers were demonstrated and exercised, followed by 4 consecutive attempts to succeed with each of these devices. The primary outcome was the improvement of completion time needed for a competent airway. Secondary outcomes were the trainees' overall reactions to the training and algorithm, and the perceptions of psychological safety (PS). The 23 staff members of the Department of Pulmonology performed a total of 552 attempts at AM procedures (4 attempts at each of the 3 maneuvers in 2 sessions), and returned a total of 42 questionnaires (4 questionnaires were not returned). Median completion times of LT and NCT improved significantly between Sessions 1 and 2 (P = 0.005 and P = 0.04, respectively), whereas BMV was only marginally improved (P = 0.05). Trainees perceived training to be useful and expressed satisfaction with this training and the algorithm. The perception of PS increased after training. An AM algorithm and training for pulmonologists leads to improved technical AM skills, and is considered useful by trainees and raised their perception of PS during training. It thus represents a promising program.

Improving Anesthesiologists' Ability to Speak Up in the Operating Room: A Randomized Controlled Experiment of a Simulation-Based Intervention and a Qualitative Analysis of Hurdles and Enablers

PURPOSE

The authors addressed three questions: (1) Would a realistic simulation-based educational intervention improve speaking-up behaviors of practicing nontrainee anesthesiologists? (2) What would those speaking-up behaviors be when the issue emanated from a surgeon, a circulating nurse, or an anesthesiologist colleague? (3) What were the hurdles and enablers to speaking up in those situations?

METHOD

The authors conducted a simulation-based randomized controlled experiment from March 2008-February 2011 at the Center for Medical Simulation, Boston, Massachusetts. During a mandatory crisis management course for practicing nontrainee anesthesiologists from five Boston institutions, a 50-minute workshop on speaking up was conducted for intervention (n = 35) and control (n = 36) groups before or after, respectively, an experimental scenario with three events. The authors analyzed videos of the experimental scenarios and debriefing sessions.

RESULTS

No statistically significant differences between the intervention and control group subjects with respect to speaking-up actions were observed in any of the three events. The five most frequently mentioned hurdles to speaking up were uncertainty about the issue, stereotypes of others on the team, familiarity with the individual, respect for experience, and the repercussion expected. The five most frequently mentioned enablers were realizing the speaking-up problem, having a speaking-up rubric, certainty about the consequences of speaking up, familiarity with the individual, and having a second opinion or getting help.

CONCLUSIONS

An educational intervention alone was ineffective in improving the speaking-up behaviors of practicing nontrainee anesthesiologists. Other measures to change speaking-up behaviors could be implemented and might improve patient safety.

Agency and Communion Predict Speaking Up in Acute Care Teams

Speaking up with suggestions, problems, or doubts is important—especially in health care action teams where each team member’s input can be crucial for the treatment of a patient. Implementing a high-fidelity simulation study, we investigated individual predictors of speaking up in acute care teams (ACTs). Participants were 27 physicians and 27 nurses from a hospital who completed measures on self-perceived agency (i.e., assertiveness, persistence, independence) and communion (i.e., helpfulness, friendliness, sociability). In two-person teams, they managed simulated critical events that required speaking up. In line with our hypotheses, we found that agency positively and communion negatively predicted actual speaking up behavior. We discuss the differential effects of agency and communion on speaking up and thereby highlight theoretical and practical implications.

A synchrotron-radiation-based variable angle ellipsometer for the visible to vacuum ultraviolet spectral range

A rotating analyzer spectroscopic polarimeter and ellipsometer with a wide-range θ-2θ goniometer installed at the Insertion Device Beamline of the Metrology Light Source in Berlin is presented. With a combination of transmission- and reflection-based polarizing elements and the inherent degree of polarization of the undulator radiation, this ellipsometer is able to cover photon energies from about 2 eV up to 40 eV. Additionally, a new compensator design based on a CaF2 Fresnel rhomb is presented. This compensator allows ellipsometric measurements with circular polarization in the vacuum ultraviolet spectral range and thus, for example, the characterization of depolarizing samples. The new instrument was initially used for the characterization of the polarization of the beamline. The technical capabilities of the ellipsometer are demonstrated by a cohesive wide-range measurement of the dielectric function of epitaxially grown ZnO.