A Roadmap to Teach Senior Residents to Facilitate Debriefings after Critical Incidents

Transcription

1 A Roadmap to Teach Senior Residents to Facilitate Debriefings after Critical Incidents Amanda D. Osta, MD Janet R. Serwint, MD Megan E. McCabe, MD Annamaria T. Church, MD Albina S. Gogo, MD Ann Burke, MD

2 Disclosures The authors have nothing to disclose AAP is providing funding for editorial overview of curriculum

3 Objectives of Workshop Identify critical incidents following which debriefing sessions for residents would be beneficial Conduct a successful mock resident debriefing session Implement a debriefing curriculum at your home institution

4 Agenda Activity Welcome and Introduction to Curriculum Journaling Worksheet Followed by pair-share Overview of Debriefing Mock Debriefing Case Small Group Discussion Large Group Discussion Steps for Implementation Wrap Up and Evaluation Time 10 minutes 20 minutes 10 minutes 30 minutes 15 minutes 10 minutes 15 minutes 10 minutes

5 Invitation to Create Curriculum AAP Section of Medical Students, Residents and Fellowship Trainees Need to address grief and loss AAP Section on Hospice and Palliative Medicine National call for participants/authors Development of curriculum to address resident grief and loss Revised to approach through resiliency

6 Why Is This Essential? Pediatric residency incredibly rewarding time in career Yet, can also be quite demanding for housestaff Implementation of new work hours has increased workload intensity, and potential for emotional detachment

7 Why Is This Essential? Distancing (withdrawing from family) while immediately protective, may lead to personal disappointment and burnout Trauma of events impacts residents Long term implications may include mental health issues, substance abuse

8 Why Is This Essential? Being engaged with patients and families results in some of most rewarding experiences Relationships with families and addressing suffering key to our profession Engaged and vibrant pediatricians must develop skills and cultivate mechanisms to maintain wellness by being present to human interactions in dynamic and mindful ways

9 Why Is This Essential? Two resident physicians in two different programs in second month of training in NYC committed suicide in August 2014 Physicians have higher rates of depression, anxiety, substance abuse and suicide compared to the general population Pediatric residents have 20% rate of depressive symptoms

10 Components of the Resilience Curriculum Part A: Understanding Grief and Loss Part B: Communication with Families about Critical Incidents and Life Altering Diagnoses Part C: Adaptive Behaviors and Coping; Mechanisms for Health Care Providers Part D: Maintaining One s Own Wellness 10

11 Tools developed for each module PowerPoint presentation- for self study or group discussion Learner and faculty guide Cases Reflections Experiential components- - Videos - Articles, narratives - Scenarios- role play or standardized patients

12 Senior Resident Debriefing: Objectives Identify situations which debriefing sessions would be beneficial List benefits of a debriefing session Recognize the need for debriefing and support in others Conduct a successful mock debriefing session Analyze the event Identify one s own emotions Inquire about perceptions of family and medical team members Ask critical questions to help team members reach closure Comment on how medical team member responses may affect patient and family interactions

13 Reflective Exercise Think about a patient care experience when: one of the trainees working with you had an emotionally challenging experience OR you were in that situation as a trainee Complete the journaling worksheet provided Share with the person sitting next to you

14 Facilitated Discussion Would anyone like to share their story? If you were involved with the patient, did you experience the event similarly to those you were supervising? What did you take away from this experience? Did you or the trainee participate in a debriefing after this experience?

15 Background Multiple national organizations have recognized and supported the needs of physicians dealing with grief and loss. IOM report: When Children Die AAP Statement on Palliative Care APA Educational Guidelines

16 Background In a study examining pediatric resident use of debriefing after a patient s death: 31% of residents acknowledged guilt 74% of residents debriefed after at least one patient s death Residents stated that they had debriefed after 30% of patient deaths Higher odds of debriefing with: Inpatient death vs. ED death Death of a previously healthy patient vs. death of a patient with chronic disease Serwint J. One Method of Coping: Resident Debriefing After the Death of a Patient. J Pediatr August 2004

17 Debriefing Primer

18 Critical Incidents Patient death or sudden decompensation Life altering diagnosis Unexpected outcome Uncertainty Inability to control outcomes Medical error Angry family Lead to strong emotional reactions that have the potential to interfere with ability to function, either initially or later 18

19 Critical Incidents During Medical Education and Practice Impact Us 19

20 Benefits of Debriefing Taking time together to identify the personal impact of grief and loss Increased mutual understanding and empathy among group members Acceptance of normal responses to distressing situation DR Hanna, M Romana Debriefing after a crisis What s the best way to resolve moral distress? Don t suffer in silence. August 2007 Nursing Management 20

21 Benefits of Debriefing Validating experiences and responses frees clinicians to return to their work on behalf of others Healthy coping skills of some group members shared with those who coped less effectively

22 We have an obligation as educators to share with learners how we have coped with feelings of anger, anguish, shame or uncertainty in caring for patients. -Novack DH et al. Acad Med,

23 A Framework for Debriefing Welcome and Introductions Factual Information Case Review Grief Responses Emotional Strategies for Coping with Grief Lessons Learned Conclusion Review purpose of bereavement debriefing sessions Invite participants to give names and answer the question: How were you involved in care for this patient and family? Review time of death circumstances What was it like taking care of this patient? What was the most distressing aspect of the case? What was the most satisfying aspect of the case? What have you experienced since the death? (Elicit physical, emotional, behavioral, cognitive, or spiritual responses) What will you remember most about this patient/family? How are you taking care of yourself so you can continue to provide care for other patients and families? Review grief coping strategies Review available resources What lessons did we learn from caring for this patient/family? Acknowledge care provided Review bereavement support available for families and staff Elizabeth A. Keene, Nancy Hutton, Barbara Hall, Cynda Rushton PEDIATRIC NURSING/July-August 2010/Vol. 36/No. 4

24 Mock Debriefing Case Introduction Case Discussion Mock Debriefing Debriefing Discussion

25 First week in July Mock Debriefing: Case Pediatric cardiology team Introduction 7AM: Katie, a 4y/o girl with idiopathic pulmonary hypertension presented for routine yearly cardiac catheterization Procedure performed by her primary cardiologist goes well Plan for discharge later in the evening or next morning Intern who admitted her in the morning, signs her out to cointern for discharge once cleared by cardiology.

26 Mock Debriefing: Case Introduction 8PM: Pulmonary hypertensive crisis Patient codes and dies. No one from primary team is present Team is rounding the next morning

27 Intern 1 Mock Debriefing: Case Introduction Usually on top of things and highly motivated Appears a bit scattered this morning Intern 2 Never saw the patient after receiving sign-out Feels that if she had seen patient, she could have noticed something, and perhaps this would not have happened

28 Roles for Debriefing Roles for debriefing Senior resident (leader) Intern 1 Intern 2 Observers (use the skills checklist)

29 Practice Scenario Use the skills checklist to note specific skills Consider what you will ask your group at the end of the session: - What skills did you notice? - What went well? - What was challenging? - Feedback for the debriefing leader?

30 A Framework for Debriefing Welcome and Introductions Factual Information Case Review Grief Responses Emotional Strategies for Coping with Grief Lessons Learned Conclusion Review purpose of bereavement debriefing sessions Invite participants to give names and answer the question: How were you involved in care for this patient and family? Review time of death circumstances What was it like taking care of this patient? What was the most distressing aspect of the case? What was the most satisfying aspect of the case? What have you experienced since the death? (Elicit physical, emotional, behavioral, cognitive, or spiritual responses) What will you remember most about this patient/family? How are you taking care of yourself so you can continue to provide care for other patients and families? Review grief coping strategies Review available resources What lessons did we learn from caring for this patient/family? Acknowledge care provided Review bereavement support available for families and staff Elizabeth A. Keene, Nancy Hutton, Barbara Hall, Cynda Rushton PEDIATRIC NURSING/July-August 2010/Vol. 36/No. 4

31 Debriefing Feedback What skills did you notice? What went well? What was challenging? Feedback for the senior resident who is running the debriefing?

32 Additional Questions Questions Who should/could ask for a debriefing? How? When should a debriefing be done? Who should be present? Who should facilitate? What is the role for the residency director? Potential Participants Medical students Interns Senior Residents Fellows Attendings Residency Director Clerkship Director Pharmacy Social Work Environmental services Other disciplines

33 Implementation Steps Potential opportunities for implementation? Barriers for implementation?

34 Next Steps We ll a link to workshop materials and the overall trainee resilience curriculum

35 Authors of Curriculum Collaboration with AAP, APA, APPD, COMSEP Janet Serwint (Johns Hopkins U) Susan Bostwick (Weill-Cornell College) Ann Burke (Wright State U) Annie Church ( U of TN- Chattanooga) Albina Gogo (UC-Davis) Dena Hofkosh (U of Pittsburgh) Marta King (St. Louis U)

36 Authors of Curriculum Jenni Linebarger (U of TX-Houston) Megan McCabe (Montefiore ) Margaret Moon (Johns Hopkins U) Amanda Osta (U of Illinois-Chicago) Deborah Rana (UC- San Diego) Florence Rivera (AAP administrative staff) OJ Sahler (U of Rochester) Keely Smith (U of Missouri-Kansas City)