The great art of learning is to understand but little at a time. —John Locke

Clinical debriefing (CD) is rapidly gaining traction as a valuable activity. CD is usually conducted as a guided exploration and reflection of clinical events in an attempt to bridge the gap between experience and understanding, with the ultimate aim of influencing future practice.1 CD has the potential to improve outcomes for staff, teams, patients and systems.2 3 The evidence for CD exists and continues to grow; benefits range from changes in staff attitudes4 to favourable outcomes following cardiac arrest.5 Despite this, some clinicians have been sceptical about the impact of CD, and there are various barriers which may limit implementation. These include lack of clear purpose, actual or perceived lack of time, lack of experienced debriefers and cultural resistance to change.6 Our focus should now be shifting towards overcoming barriers to implementation, a disappointingly difficult feat.7 8 The paper by Paxino et al 9 in this issue of BMJ Quality & Safety responds to this call and suggests that a lack of standardised terminology to describe CD practices may be part of the implementation problem.

Paxino et al use scoping review methodology to explore how contextual factors relating to interdisciplinary CD are described in the existing literature, and whether these can be used to differentiate approaches to CD. They explore 46 studies using the ‘Who–What–When–Where–Why–How’ framework, with particular emphasis on contextual factors related to the ‘What’ and ‘When’ elements to differentiate between CD approaches. Based on their findings, they reconceptualise the terminology of CD practices into ‘prompted’ (further differentiated into ‘immediate’ and ‘delayed’) and ‘routine’ (further differentiated into ‘postoperative’ and ‘end of shift’), and propose a move away from a one-size-fits-all way of describing CD practices. They argue that there are potential problems with some pre-existing terminology, such as the temperature metaphors of ‘hot’ and ‘cold’ debriefs. For example, a ‘hot’ debrief is generally one done immediately following an event10; however, this terminology may have negative connotations regarding how the debrief should be done (fast, rushed) or the emotional state of the participants (upset, stressed). Moreover, they highlight that pre-existing classifications of CD practices are inconsistent, ambiguous and potentially inaccurate. A lack of standardised terminology may limit implementation of CD by creating confusion among staff wishing to facilitate or participate in a CD, lack of confidence in initiating the correct approach for a specific context, inconsistent delivery, unclear intention of the debrief and potentially inappropriate implementation which may lead to harm.

These results are a welcome addition to existing review articles of current CD practices, such as a recent systematic review of CD tools,1 and instructional ‘top tips’ papers.11 However, despite this useful recategorisation of CD approaches (routine and prompted), it is important to recognise that different aims and underlying mechanisms will exist for these alternative forms of CD. A deeper appreciation of these mechanisms is essential in order to align delivery of CD to desired benefits and to overcome barriers to implementation. We have detailed below two examples of such underlying mechanisms and how they relate to both Paxino et al’s categorisations and to the overarching aims of a particular CD.

While the idea of conducting a CD routinely is not new, for example, postoperatively or at the end of a shift, CD is more frequently carried out following adverse or unanticipated events.1 Paxino et al found that just 14 of the 46 studies referred to routine CD (vs prompted). Embedding CD into a routine context, making it proactive rather than just reactive, could have considerable benefits in terms of learning. First, this encourages us to move away from only thinking about learning from when things go wrong (aligned with more conventional patient safety principles) towards generating learning from success and everyday practice (aligned with contemporary views on patient safety). Second, if staff become accustomed to having these types of discussions in low-stakes scenarios, they may be more comfortable and confident to engage in CD following a challenging or emotive case, as discussed further below.

Considering the benefits of routine debriefing raises the question of why it is not yet common practice. Although the answer to this is likely multifaceted, culture has been proposed as one of the main barriers to implementation.6 Peter Drucker, a management consultant, famously stated that ‘culture eats strategy for breakfast’.12 In the healthcare context, we must appreciate that no matter how well we define CD, design tools for rehearsal or train facilitators, widespread CD uptake will not succeed unless it is culturally accepted. In healthcare, influencing culture can be challenging and the road is seldom smooth. Psychological difficulties can be experienced during transitions to change,13 including resistance, cynicism or irritation among some staff members regarding, for example, the perceived time investment for CD in a busy and pressured clinical environment.

There is a paucity of literature to draw upon related to cultural challenges in implementation of CD. However, work does exist examining healthcare cultural change on a broader scale. Scott et al 14 highlight key sources of resistance to cultural change in healthcare, including: lack of ownership by individuals or groups, negative external influences from stakeholders, lack of appropriate leadership and cultural diversity between professional subgroups. The common theme is that people are an essential part of the change process. In figure 1, we suggest potential methods for how we can positively influence the cultural shift required to accept and embed CD. These apply to both the routine and prompted contexts, and are based on our own experiences and opinions, using Scott et al’s work and applying it to the CD context. The ultimate aim is to make CD part of our routine practice, and promoting cultural change is an important step in making this happen. However, we must be patient with these changes, prioritising sustainability over short-term success. We advocate more emphasis on addressing culture to influence effective implementation of CD, with a view to delivering CD for learning from routine clinical events.

Engaging people to influence clinical debriefing (CD) culture in healthcare. GMC, General Medical Council; NHS, National Health Service.

So far, we have considered routine CD as a process designed to create learning points that will impact future practice and ultimately enhance patient safety, known as ‘debriefing-to-learn’.15 Moving to consider Paxino et al’s second categorisation of prompted CD leads us to also consider the potentially different aims and mechanisms at play in that context. The differences are likely to be due to the level of staff emotions potentially present in a prompted CD which are less likely to be relevant to routine CD.

In terms of the aim, ‘debriefing-to-treat’, as a way of attempting to reduce the longer-term psychological impact of a traumatic event, has been shown to be unhelpful and potentially harmful.16 The underlying psychological mechanisms for this association are not fully understood, but may involve re-exposure serving as further trauma, or the group setting interrupting normal individual adaptive processes and preferences.15 When individuals or teams show high levels of distress, the purpose of a CD should change accordingly, and a ‘debriefing-to-manage’ approach has been advocated.15 This is where the focus of the debrief is on giving participants space to focus on reactions to an event, rather than focusing on the experience itself in detail. Paxino et al’s scoping review9 excluded papers primarily describing psychologically focused debriefings, but noted that some of the included studies ‘reported an intersection between quality improvement and supporting the emotional and psychological needs of team members’. Therefore, the aim of a prompted CD may be either to learn, to manage emotional responses or an amalgamation of both.

Human emotional responses are inconveniently unpredictable, both in terms of individual responses to the same event and in proportionality of response in relation to the clinical significance of the event. A team that appears keen to explore the lessons from a patient safety perspective soon after a clinical event may consist of some individuals who might find such exploration more triggering than they, or others, had anticipated. This highlights that learning following prompted CD may be complicated by the impact of the event.

The relationship between learning and emotions is complex, but is of growing interest to both medical educators and organisational scientists. Medical practice involves significant emotional experiences, and such emotions can have important and long-lasting effects on memory, cognition and learning. For example, stress has been associated with greater memory consolidation, but also increased inaccuracy in the detail of what is recalled.17 Some learning theories that are particularly pertinent to health professionals’ education incorporate emotions as a core element of the pedagogical process.18 One such example is transformative learning (TL), a theory describing learning that challenges established perspectives through acknowledgement of the ways in which pre-existing assumptions and relationships influence the meaning that is derived from new experiences.19 Unlike many pedagogical theories, TL resonates with the complex emotional and social reality of the clinical workplace. It explicitly incorporates an emotional ‘trigger’, such as guilt or shame, that initiates perspective transformation.19 The essential affective component as part of the learning process is, however, at odds with the prevailing rhetoric of heightened emotion presenting an obstacle to learning in both simulated and real clinical environments.15 20 It would therefore seem that there is much left to explore and understand about CD with regard to how much emotion is too much, and the complex relationships between emotion, learning and psychological sequelae. Paxino et al seek to remove assumptions about the emotional state of participants in their recontextualisation of CD practice, by replacing current ‘hot’ and ‘cold’ terminology. While this does seem prudent, it may be both unrealistic and unhelpful to entirely disentangle emotions and learning in relation to CD.

Paxino et al present a comprehensive review of the existing literature of CD practices, and propose the new categories of routine and prompted CD. This useful distinction helps us appreciate that these types of CD differ not only in terms of the ‘When’ but also the ‘Why’ regarding the aims of the debrief—to learn and/or to manage emotional responses. It is likely that there are different factors that facilitate and hinder the implementation of routine and prompted, and two examples (culture related to routine CD and the role of emotions in learning in prompted CD) have been explored. As we move away from a one-size-fits-all perspective of CD practices which has existed in the past, understanding the distinction between types of CD, in terms of their aims and underlying mechanisms, is an important step towards effective implementation. For those wishing to practise CD, Paxino et al’s new categorisation may help in clarifying aims and developing an implementation strategy. We encourage both clinicians and researchers to further explore concepts such as context, culture and the relationship between emotions and learning related to CD in order to build our collective understanding of how to optimally deliver CD for healthcare staff.

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Thank you to Dr Samantha Smith for her constructive feedback on this editorial.