Debriefing critical incidents in the Emergency Department
Executive summary
Emergency Departments (EDs) have long been recognised as one the most stressful specialities with the highest levels of burnout (Healy & Tyrrell, 2011). Lack of support following critical incidents is one of the key contributors to a stressful work environment for nurses working in EDs (Healy & Tyrrell, 2011). The most severe form of stress ED nurses experience is Post-Traumatic Stress Disorder (PTSD). The Ministry of Health (2004) predicts increasing demand for specialist services like ED due to New Zealand’s aging demographic. However, little consideration is being given to how we might sustain current and future ED nurses by managing work-related stress.
Given the current literature, this submission recommends that:
- Formal support could include CBT for those with PTSD, alongside restorative supervision for all ED nurses
- Further research should be conducted that specifically considersthe unique culture of ED staff.
Reducing stress following critical incidents through the implementation of formal support is one way that District Health Boards (DHBs) can value and develop their nurses, enabling them to sustainably care for patients. It may also reduce burnout and turnover, thus mitigating DHBs' Health and Safety liability and reducing related costs.
Submission
Emergency Department nurses are regularly faced with traumatic situations, such as failed resuscitation, cardiac or respiratory arrest, violence, abuse, aggression, critically ill patients, and death. These situations, often referred to as ‘critical incidents', are described as “a self-defined traumatic event that cause[sic] individuals to experience such strong emotional response that usual coping mechanisms are ineffective” (Magyar & Theophilos, 2010, p. 500). Due to such incidents, the Emergency Department (ED) has long been recognised as one of the most stressful specialities with the highest levels of burnout (Healy & Tyrrell, 2011).
What is done to support EDnurses following a critical incident is a pressing practice issue. Healy and Tyrrell (2011) found that lack of support following critical incidents is one of the key contributors to a stressful work environment for doctors and nurses who work in ED. The most serve form of stress that ED nurses experience is Post-Traumatic Stress Disorder (PTSD). Such stress can lead specifically to higher absentee rates and high turnover of staff (Morrissey, 2005). Nurses traditionally deal with critical incidents by discussing them informally with other nurses at meal breaks or social gatherings (Morrissey, 2005). This type of support is shown to be insufficient (Gillespie & Gates, 2013). In fact, Morrissey (2005) maintains that neglecting to protect nurses from stress at work is a Health and Safety issue.
The New Zealand Ministry of Health (2004) statistics show a rapidly aging population, so we know there will be an ever increasing strain on ED staff. Consideration is being given as to how we might grow the healthcare workforce (Ministry of Health, 2004). However, little consideration is being given to how we might prevent turnover and burnout in current and future nurses by managing work-related stress.
Evidence from literature to support change
A structured, assisted programme, such as debriefing after critical incidents, is the well-recognised alternative to informal social discussion (Magyar & Theophilos, 2010). But is this the best method to reduce the negative effects of work stress on ED nurses? This submission presents what current literature suggests should be provided to help ED nurses deal productively with the stress of critical incidents.
The definition of debriefing depends on the model used. However, it generally involves a process during which “participants are asked about their emotional reaction to the incident” (Farrell & Dempsey, 2010, p. 2303). There is very limited literature looking specifically at the population of ED nurses. Healy and Tyrrell’s (2013) study is one of the few that addresses debriefing of ED staff. Their research consisted of a descriptive survey of ED doctors and nurses in Ireland. Out of the 103 (69%) who responded, 87 (84%) perceived debriefing as ‘important’ or ‘very important’ (Healy & Tyrrell, 2013). Healy and Tyrrell’s (2013) main conclusion was thatno formal debriefing guidelines or policies existed, and that such guidelines, along with other strategies, should be implemented to reduce the effects of stress on staff.
Studies by Theophilos, Magyer, and Babl (2009) and Ireland, Gilchrist and Maconochie (2008) were of current debriefing practice and perceived needs of senior ED doctors and nurses. Theophilos et al., conducted their study in all 13 paediatric EDs throughout New Zealand and Australia, while Ireland et al.’s (2008) sample was of UK EDs. Both samples also rated debriefing as very important. Ireland et al. (2008) found that 72% of responders said there was no policy for debriefing in their department, while almost 90% of paediatric ED staff did not have a department-specific protocol on debriefing (Theophil, et al., 2009). The main conclusion of both these studies was that best-practice guidelines for critical incident debriefing should be developed.
All three studies that gave questionnaires to ED nurses strongly acknowledge the perceived need of ED nurses for debriefing. But they did not provide any evidence that debriefing would reduce stress. Review of existing studies of debriefingby Rose, Bission, Churchill and Wessely (2002) and Rose, Bission and Wessely (2003) sought to clarify existing evidence. These reviews concerned the efficacy of single session of psychological “debriefing” in reducing psychological distress and prevention of the development of PTSD after traumatic events. It is the contribution of such reviews that have fuelled the debate regarding the effectiveness of debriefing (Ireland et al., 2008). Both Rose et al. (2002) and Rose et al. (2003) concluded that single-session psychological debriefing should not be routinely carried out as there is no evidence to support its usefulness in the prevention of PTSD. Instead, a screening and treatment model could be implemented. One of the possibilities for negative effects of debriefing discussed by Rose et al. (2003) was that debriefing could cause secondary traumatization. However, critics such as Ireland et al. (2007) argued that Rose et al.’s (2003) review was also not applicable to the target population of ED nurses because the sample population consisted mainly of patients.
However, following reviews from Rose et al. (2002) and Rose et al. (2003), the using of the ‘screening and treatment model’ approach for victims of trauma who do suffer from PTSD has become the preferred approach. Research by Belaise, Giovanni and Isaac (2005) has shown Cognitive Behavioural Therapy (CBT) to be more effective than debriefing in treating PTSD. Roberts, Kitchiner, Kenardy, and Bisson (2010) also agree that trauma-focused CBT was the more effective intervention for those who exhibit symptoms of PTSD following an incident. This was the main conclusion of Roberts et al.'s (2010) review of 15 studies covering a range of psychological interventions. However, none of these studies included hospital staff in their sample population, therefore their findings are not generalizable to the population of ED nurses.
Halpern, Gurevich, Schwartz and Brazeau (2008) believe using the “screen and treatment model” as an alternative to debriefing has two disadvantages. Firstly, although it does offer treatment to those who develop PTSD, it is oftenprovidedone-three months after the critical incident and so does not address the more insidious, post-traumatic consequences such as depression, substance abuse and burnout. Secondly, emergency services were left with little direction as to how to respond immediatelyfollowing a critical incident. Halpern et al. (2008) conducted their study exploring the experience of Emergency Medical Technicians (EMTs) and their views on possible interventions. The purpose was to assist in the development of interventions that take into consideration the culture of EMTs. Halpern et al.'s (2008) main conclusion was that, immediately following an incident, EMTs should be offered: “(1) supervisor support; and (2) a brief timeout period in which to talk informally, often with peers” (p. 148). They concluded that the biggest barrier to EMTs accessing support was the perceived stigma associated in appearing vulnerable, which contributed to low access of support (Halpern et al., 2008).
One solution offered by EMTs to combat a perceived stigma of seeking support was to make supervisor support mandatory (Halpern et al., 2008). Mandatory supervisor support would be very similar to supervision. Clinical supervision is another emerging strategy for preventing burnout and reducing stress. There are many different forms of supervision, due to the diversity of contexts in which supervision is applied. As Dilworth, Higgins, Parker, Kelly, and Turner (2012) point out, this can often be a major barrier to implementation of supervision. Another barrier is the resistance of the organisation due to staffing or budget constraints (Dilworth et al., 2012). Despite these barriers, it is still very much the view of Dilworth et al. (2012) that clinical supervision would be beneficial and should not be overlooked on these grounds.
Restorative supervision is the specific form that could help ED nurses. Restorative supervision is concerned with how the nurse “responds emotionally to the stresses and demands of working” (Driscoll & O’Sullivan, 2007, p. 14). After their success using restorative supervision in prior research, Wallbank and Woods (2012) are participating in a current UK programme implementing restorative supervision to 1800 medicalprofessionals. The programme's latest results show restorative supervision “reduced burnout by 43% and stress by 62%” in 249 senior public health nurses (Wallbank & Woods, 2012, p. 23). Research conducted by Koivu, Saarinen, and Hyrkas (2012) also agreed with Wallbank and Woods (2012). Koivu et al. (2012) concluded that supervision used in association with other job and personal resources would promote workplace wellbeing. However, no literature has yet documented the use of restorative supervision specifically for ED nurses.
Implications for nursing practice
To date there has been little research on the effectiveness of debriefing for ED staff. There has been research conducted on a range of population groups which concludes there is no evidence to support that debriefing as a standalone intervention can reduce stress (Rose et al., 2002). However, debriefing and any alternatives have not yet beentested on a population of ED nurses and their unique culture (Halpern et al., 2008). There is a perceived need by ED nurses for debriefing following a critical incident (Healy & Tyrrell, 2013) and there is research that calls for the development of a protocol subsequent to an incident (Gilchrist & Maconochie, 2008). I believe this together provides sufficient grounds to recommend that formal support is needed for ED nurses to help reduce the negative effects of stress imposed by critical incidents, and that specific research on this population is required.
Recommendations
Given the current literature, this submission recommends that formal support is needed to mitigate the negativeeffects of stress imposed on ED nurses by critical incidents. This could take the form of CBT for those who exhibit PTSD symptoms, alongside restorative supervision as a mandatory requirement for all ED staff to promote workplace wellbeing, reduce work-related stress, and prevent burnout. Secondly, further research should be conducted that specifically considers the unique culture of ED staff in order to adequately develop best practice guidelines for the management of critical incidents in EDs.
With growing demands on New Zealand’s healthcare system, it is important to advocate for the rights of nurses in order that they might sustainably care for their patients. Reducing stress following critical incidents, by the implementation of formal support, is one way that District Health Boards (DHBs) can value and develop their nurses. Reducing PTSD and burnout could also mitigate DHBs' Health and Safety liability. Longterm, such support could reduce turnover and so reduce future costs for training highly skilled ED nurses.
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