Critical Incident Stress Debriefing

fiestynurse · Jan 4, 2004

Traditionally, acknowledging symptoms of distress has been viewed as evidence of a personality deficit or inadequate skills to perform in the job. I was told early on in my nursing career that if I was going to break down and cry everytime a patient died, I shouldn't be in this profession. Nurses are expected to keep a professional and emotional distance from our patients, which I always found impossible. I always felt that my sensitivity is what made me a great nurse. Looking back on my career I would have liked to participate in some sort of stress debriefing session because I never knew how to handle the intense feelings that I would get after an extreme patient care event.

Research has identified acute stress reactions in many situations involving nurses following the death of a patient or colleague. We suffer from battle fatigue. Many of us are the "walking wounded." Symptoms described include recurrent dreams, feelings of detachment, dissociation, guilt about surviving, anger and irritability, depression, memory or concentration impairment, somatic disturbances, alcohol and substance use, and re-experiencing of symptoms when exposed to trauma stimuli. These reactions have important implications for individual workers and their families who are attempting to deal with the aftermath of traumatic event. This may be why so many nurses marry doctors or individuals in the emergency response system, such as firefighters, police officers, correctional officers, etc. because they can relate to their experiences. In addition, these physical, emotional, cognitive and behavioral reactions in nurses have a profound effect on the ability of nurses to continue to be responsive to the needs of their patients.

It is true that most nurses possess the internal resources to deal with most work-related events and I agree with some of the posts regarding the ability of nurses to support one another. But, I think we can benefit from limited extra assistance in extreme circumstances. Group interventions allow for ventilation of feelings, encourage mutual aid and reinforces innate abilities to cope. Follow-up individual sessions are available to workers experiencing acute distress. I would encourage nurses to take advantage of employee assistance programs. (Most don't)

I am sorry that some of you had bad experiences with debriefers. It is important to find an individual that is experienced in working with nurses. It is also imperative that the organization does not view the debriefing as an opportunity to critique the incident or to defuse union agitation over particular concerns about management or occupational safety. Further, the debriefer should ensure that nurses do not expose themselves to risk by divulging information about their actions that may result in liability.

Burns & Harm (1993) report the results of a survey of 682 emergency room nurses. Thirty-two percent of the nurses had attended crisis debriefings and 88% of those who had attended debriefings found them helpful. Robinson & Mitchell (1993) similarly report that 90% of 288 emergency and hospital workers who attended debriefings found them helpful.

Example of a Crisis Debriefing in action:

The incident occurred during an evening shift on a locked psychiatric admissions unit. A male patient who was acutely psychotic became violent and aggressive toward staff. In the course of the incident, he tore apart a metal garbage can and used the sharp edge as a weapon with which to threaten the life of nursing staff members. In the ensuing crisis, several nursing staff locked themselves in the nursing station, one nurse locked herself in the bathroom and two became barricaded in patient rooms. Police were called, as security guards in Canadian hospitals do not carry weapons. In the intervening time until police arrived, the patient began kicking the glass in the nursing station wall and attempted to climb the walls, which did not reach to the ceiling. The walls shook violently and at one point his hand was visible over the top of the partition. Nurses in various areas had no means of contacting one another and were unsure if a colleague had been injured or killed. In the end, the patient was subdued and removed. Nurses remained on duty for the duration of the shift and were instructed to complete incident reports.

Debriefers were contacted one week after the occurrence, as nursing staff remained distressed and angry about the incident and the organizational response. After obtaining information about the event, a debriefing was arranged for the following day. The debriefers insisted that the debriefing be carried out in a room far removed from the unit and that nursing staff be assured that they would not be interrupted for a two-hour period. All staff in attendance that evening were invited to attend, including nursing staff from the affected unit and nursing staff from the next unit, who watched the incident through a locked glass door. Eleven staff members participated in the session. The debriefers consisted of two mental health professionals with expertise in this area, one from within the organization and one external to the organization, and a peer debriefer from an affiliated facility.

The debriefing began with an introduction of the group leaders and their qualifications. When the leaders were assured of the group's comfort, the rules of the debriefing were reviewed and all members agreed to abide by the rules.

The group members were then invited to introduce themselves and describe their involvement in the event. The session moved quickly into a description of their immediate reactions to the event. Within a very short period of time several staff members became tearful as they expressed their colleagues and friends were being attacked and their frustration with their own inability to intervene in any way. In this process, many became aware for the first time of the events as they unfolded in various parts of the unit. Staff members spontaneously supported one another and reassured one another. As the debriefing continued, staff discussed ongoing fears and reactions to the event. Several were experiencing sleeplessness, nightmares and intrusive thoughts. Others felt overwhelmed by references to violent incidents in the news. Most experienced difficulty in performing their duties at their usual level of competence and self-assurance. These reactions were normalized within the context of reactions to life-threatening experiences, and the support that they demonstrated to one another was affirmed.

A theme that continued to arise during the session, however, was anger that the safety needs of staff were not more adequately addressed by the organization. While traditional CD approaches steer clear of any operational debriefing, avoiding this topic entirely would have reinforced their belief that no one cared about their safety. In this context, one individual, who was the union representative, became very tearful, feeling that it was her fault that these issues had not been addressed. The senior staff member on duty that evening similarly took full responsibility. Allowing this issue to be raised provided an opportunity for the other staff to assure these individuals that the responsibility did not rest on their shoulders. Out of concern for these individuals and the safety of staff in general, the leaders then moved to an organizational intervention. Staff members developed a plan about how they would advocate for themselves and work toward positive change in the organization. As often occurs at these times, some members asked whether the debriefers could take the lead in this. It was explained, however, that this would violate our agreement to keep the content of the debriefing confidential. The group appreciated this and felt that the support they received from one another and the plans they had developed in the session empowered them to collectively address their concerns in the organization.

Calfax · Feb 5, 2004

I dunno,

I've been to one..........it was held about 3 days after the incident. Briefly, the patient was a psych patient pesenting to the ED for "depression" on a busy day. Triaged to WR where he sat for about 3 hrs before taking the loaded 45 out of his backpack and blowing his brains out in front of the triage desk. Boom.

I remember we were not so shocked and bothered by what he did, as the fact that he sat out there for 3 hours with a loaded 45. We tried vehemently to convince the administration to install metal detectors and to up security....but they refused, saying it would look bad for the hospital's image to have metal detectors in the ER.

It was then that we realized that we were really at a damage control sesson, not anything really to our benefit and people basically got up and left.

We take care of each other, mostly. After really stressful nights we all go out to breakfast together.....because, usually we haven't eaten much on those nights. We decompress. At parties, we have the five minute rule.....you can only talk about work for 5 minutes. We'll grab one of the cool physicians sometimes and do a work-thru of what we did to see if we could have done things better. Beyond that, what can you do? You can't control everything.

jayne109, RN · Feb 5, 2004

IT is amazing that I came upon this thread when I did. I work ona rural fire dept as an EMT and I am a Neuro nurse. We got a call for initially 2 pre teen boys burned. WE did not go in thinking the worst. We got there there was one 100% 3 rd degree burned (playing with matches and gasoline-gas flashed-blew boy away)12 y/o talking to us and we could do nothing but give oxygen and keep him talking. WE flew him in but they had to tube him before the aircraft lifted. TI was really hard on all of us.

We held our own CISD right after the incident with our fire chief, who had not been on scene-he had just monitored the radio- at the fire station. He did a really goood job facilitating-he gave everyone a chance to talk and vocalize what they saw, and basically congratualted us-in a way- on how well we handled our selves on a very bad call. Hopefully that is the worst. I would rather work 1000 codes than one pediatric code or severe burn. I had to hug on my 11 year old brother and remind him of the dangers of fire and gas.

Just my $0.02! :cool:

RNin92 · Feb 5, 2004

My thoughts are mixed on CISD. I've been to one and it was ok. It was run by crisis workers from our crisis line staff. Everyone was there...EMS, ED docs and nurses, chaplains, OR crew...

Ours was a 16 y/o stabbing victim who really was DOA. We worked him for about 45 minutes...never had anything. The knife ripped through the ventricles. Can't even describe the room. Looked like the stabbing took place in our trauma room.

But here's the rub...most of us are the parents of teenagers. Mine showed up in the middle to pick me up from the end of my shift...yea...like I could leave!

But his eyes were wide-opened that noc. When I came flying out of the room for the O-Neg...it was the first time I realized how much of that kid's blood was on me.

Did the CISD work?

Well, I slept better after. But we had margaritas after the CISD soooo...who knows for sure.

I know this much...I COULD NOT have survived without my fellow ER nurses. COULD NOT. End of story.

kc ccurn · Feb 5, 2004

Research has identified acute stress reactions in many situations involving nurses following the death of a patient or colleague. We suffer from battle fatigue. Many of us are the "walking wounded." Symptoms described include recurrent dreams, feelings of detachment, dissociation, guilt about surviving, anger and irritability, depression, memory or concentration impairment, somatic disturbances, alcohol and substance use, and re-experiencing of symptoms when exposed to trauma stimuli. These reactions have important implications for individual workers and their families who are attempting to deal with the aftermath of traumatic event. This may be why so many nurses marry doctors or individuals in the emergency response system, such as firefighters, police officers, correctional officers, etc. because they can relate to their experiences. In addition, these physical, emotional, cognitive and behavioral reactions in nurses have a profound effect on the ability of nurses to continue to be responsive to the needs of their patients

I thought that this was very intersting to read! The only time I've been involved in CISD was many years ago. I work in ICU and we had a 2 year old, NAT that died. many of us were called to testify. We did have a CISD a few days after he died, but nobody who took care of him knew about it, I just happened to be working when they showed up. It really wasn't anymore helpful than destressing with your coworkers.

I was very disappointed though at the number of times when we HAVEN'T had one. I was working the day of the Columbine High School shootings and took care of many of the children that were injured. To my knowledge, we have not had any debriefings about the shootings since it happened 5 years ago. The only "debriefing" we had was a huge "grand rounds" with EMS, police, flight team, some ED and some ICU. The discussion was more along the lines of what did we learn with this incidence to use if it happens again. We saw graphic video tape from inside the school. I think my nightmares are worse after seeing that video!!!

Debriefing is very important to do! I think that teams are important to have in place. But they must be utilized correctly. As nurses we have to be careful too, we can't unload on our fellow nurses all the time, then we're all burned out and no good to anyone.