1. Hammerle, Anna BSN, RN, ACLS/BLS, ATCN
  2. Devendorf, Carol MSN, RN, CCRN, CEN
  3. Murray, Charlotte BSN, RN
  4. McGhee, Timothy MSN, RN


Enhancing staff support with debriefing programs


Article Content

Moral distress in the healthcare environment is a phenomenon that's been broadly discussed and partially attributed to compromised practice standards, workload, and fatigue. Frequent high-stress encounters with life and death, or critical incidents, can be detrimental to the physical and mental health of staff, and sometimes result in compassion fatigue-a unique form of burnout where one feels emotional exhaustion and depersonalization, resulting in poor performance.1-5

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

ED workers are particularly susceptible to moral distress and compassion fatigue. Due to the frequent exposure to critical incidents, such as physical and sexual trauma, resuscitation of patients with cardiac or respiratory arrest, and mass casualties, the emergency nurse is at high risk. Dealing with the loss of a child is particularly taxing on the emotional well-being of the caregivers involved.6 These critical incidents produce stress that can lead to long-term problems, such as posttraumatic stress disorder, generalized anxiety, and depression. Studies show that half of all nurse turnovers are attributed to work stress.7 A debriefing program can be an effective tool to quickly mitigate stress after critical incidents in the ED.



Healthcare is frequently compared with other high-risk occupations, such as law enforcement and the military, both of which have formal debriefing programs after major incidents.8 Group debriefing practices following critical incidents provide staff with the support needed to counteract the negative impact of high-stress situations. These sessions allow the involved staff members to vent their frustrations and concerns-without fear of retribution-and to deal with unsettled feelings after a critical incident. Debriefing sessions improve patient outcomes, identify training gaps, and boost morale.8


There are several elements to consider when developing a debriefing program. Debriefing sessions should be held in a private place where all team members feel safe and can speak openly. The groups should be multidisciplinary and include the attending physician, nurses, unlicensed assistive personnel, the hospital chaplain, social workers, and others. An experienced debriefer who doesn't have a direct connection to the incident should mediate the sessions. It's important to hold these meetings after all critical deaths, usually within 24 to 48 hours; however, they shouldn't be mandatory.


Sessions should be initiated by the debriefing coordinator who invites all key team members involved in the patient's care.6 They should involve several open-ended questions inviting the participants to express their personal and professional thoughts about the death.6 For an example of a critical incident in which staff may benefit from a debriefing session, see The scenario. A session format is provided in Table 1. Debriefing sessions should last approximately 1 to 2 hours and finish with a survey, asking how informative and beneficial participants found the exercise.

Table 1: Session for... - Click to enlarge in new windowTable 1: Session format

Implementation and resistance

Debriefings are an effective tool for increasing staff morale, yet some staff members fail to see how the process can be beneficial. Some may be fearful of exposing failures in practice, whereas others simply aren't comfortable sharing their emotions with colleagues.8 Others may protest based on the time constraints and logistics involved in gathering all participants in the same place at the same time.8 Other challenges involve finding someone experienced in leading debriefings and the financials of compensating attendees.


Providing information about critical incident stress debriefings and educating staff and leaders about moral distress, compassion fatigue, and secondary traumatic stress are essential for understanding and buy-in. The toll of stress on healthcare providers in regard to their physical, emotional, and cognitive well-being, as well as their job performance, should also be discussed. One suggestion to help staff buy in to the implementation of a debriefing program is to develop and introduce an informative presentation during an ED staff meeting.


As previously mentioned, a debriefing program is multidisciplinary. As such, hold separate informational meetings with medical directors, social workers, and chaplains. An appropriately trained individual who can lead the debriefing meetings is necessary. The local fire department typically has a designated person who mediates similar debriefings; this person can be identified and recommended for the job. A summary of these meetings can then be presented to upper management for approval.


Reducing stress

Emergency nursing is a highly sought-after career and loved by many. Nevertheless, it's becoming more common for staff members to experience anxiety, irritability, fatigue, and absenteeism. Some nurses avoid certain types of patients for their self-preservation and well-being. Staff members are leaving the ED in large numbers and, sadly, some are leaving nursing altogether. ED nursing can be a challenging yet rewarding profession in which nurses are expected to be at the top of their game, providing competent and compassionate care. Our communities need these experienced individuals who must be fulfilled in their roles as healthcare providers. A debriefing program is vital to enhancing staff support. If implemented, these measures can help protect and preserve the well-being of nurses devoted to emergency nursing.


The scenario9

An ambulance calls in to an ED. "Child down" is broadcast. The staff readies the pediatric code room. An 8-month-old is brought in on a stretcher. The child isn't moving or breathing. A lengthy resuscitative effort ensues. The child is an infant of someone the nurses know. The mother found the infant not breathing in her crib. Police have been notified. Was this a sudden infant death, neglect, or possible homicide? The mother is crying hysterically and emergency personnel, the chaplain, pediatricians, and others are coming in and out of the treatment room. The resuscitative code is ended when no success comes from the emergency interventions.


Following the code, the primary nurse feels numb, moving on to caring for three other patients and taking report on a fourth. A new graduate nurse who assisted with the code is crying in the break room, feeling overwhelming sadness and wondering if they really did everything they could. How can she possibly continue to work in an environment with such tragedy? The respiratory therapist is angry, feeling that the child was neglected and abused as evidenced by bruising found down her sides and back. It's the third child death that week, and all staff members are feeling helpless.




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