9 Key elements in communication: briefing and debriefing

SBAR (courtesy of the NHS Institute for Innovation and Improvement)

S Situation

B Background

A Assessment

R Recommendation

See the NHS Institute for Innovation and Improvement website at http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/sbar_-_situation_-_background_-_assessment_-_recommendation.html.

Briefing

Among the implications of the term ‘briefing’ is that it is a one-way flow of information, from one person who ‘knows’ things to another who does not know them. In the context of human factors performance, however, this is not always the case. And, as we know, ‘Two monologues don’t make a dialogue,’ so effective briefing is more than two people not listening to one another.

The key component of briefing is that it is a sharing of information, some of which may be thought to be obvious and, therefore, not worth saying. However, the context is complex and a number of features need careful consideration, including:

1 Why do we brief?

2 What is included (and excluded)?

3 What group features need attending to?

4 Managing disagreement and conflict.

Activity Box

Consider the following scenario. What would be the purpose of briefing a third party?

An elderly lady has been admitted to the orthopaedic ward from theatre with a fractured hip, which has been pinned today. She is on the postoperative protocol. She is anxious about her husband at home as she is his carer. She has chronic obstructive pulmonary disease and is on intermittent bronchodilators and, currently, antibiotics. You are the daytime ward nurse handing over to the night shift.

How would you structure your brief?

The agenda for a briefing would invariably depend on the group’s purpose: a ward team would experience a different briefing than a group in a theatre preparing for surgery. Regardless of the content of the briefing, the structure should be flexible enough to respond to changing circumstances and personnel.

Among the challenges of a briefing is the complex nature of groups. It is beyond the scope of this chapter to go into detail, other than to say that the larger the group, the more challenging its features. For instance, in a group of three people, there are six possible interactions, thus:

Add one more person and the number of possible interactions rises to 24; one more person and there are 120 potential senders and receivers of ‘messages’. Invariably most of these are non-verbal and a combination of these, along with the sheer number, mean that many communications are not received. It does not mean that they are not sent.

You may like to explore this by watching again the video produced in the wake of the death of Elaine Bromiley that we looked at in Chapter 1. The actors playing the consultants and nursing staff communicate their concerns vividly to us as an audience, but fail to do so to one another. You can watch the video at http://www.institute.nhs.uk/safer_care/general/human_factors.html.

Among these invisible communications are social phenomena such as status (both formal and informal), authority, charisma and other personal characteristics. Responses to these are unpredictable and can include deference, (passive) aggression, compliance, etc. Among other things, these can lead to a phenomenon called ‘groupthink’ (Janis 1982), which has the following features:

illusion of invulnerability: creating excessive optimism that encourages taking extreme risks
collective rationalisation: discounting warnings and not reconsidering assumptions
belief in inherent morality: belief in the rightness of a cause and therefore ignoring ethical or moral consequences of decisions
stereotyped views of out-groups: negative views of differing perspectives
direct pressure on dissenters: pressure not to express arguments against any of the group’s views
self-censorship: doubts and deviations from the perceived group consensus are not expressed
illusion of unanimity: the dominant view and judgements are assumed to be unanimous
self-appointed ‘mind guards’: protection of the group and any perceived leader from information that is problematic or contradictory to the group’s cohesiveness, view and/or decisions

In the political world this has led to disastrous military interventions (e.g. the Bay of Pigs in 1962) and in science and technology to the decision to launch the space shuttle Challenger in 1986, against the initial recommendation of an engineer who had doubts about the capacity of one of the fuel seals on the rocket booster.

You may be able to think of examples from your own or others’ practice: they are memorable because ‘groupthink’ can lead to poor outcomes.

Debriefing

Debriefing is defined as an in-depth analysis of a task after the event and in medical education is a post-experiential learning episode analysis, allowing the individual to explore in depth what they have learned about the task and themselves during the experiential event (Janis 1982).

Routine debriefing need not differ from debriefing after, for example, a critical incident and should have some, if not all, of the following features:

everyone sharing issues about personal performance
addressing emotional concerns
avoiding overpersonal criticism: debrief should see error as an opportunity for learning rather than a sin to be punished
specific (i.e. data based) and constructive
addressing non-technical as well as technical skills
developing strategies to avoid similar situations in future

A debrief should allow colleagues to describe what happened within the clinical scenario and then explore ‘what’ and ‘why’ in more depth. It should incorporate the entire group involved in the clinical episode and encourage reflection of each individual about all aspects of the clinical event, including their role, behaviour and effectiveness. Thus an effective debrief needs to be flexible and a positive learning experience, taking people around the experiential learning cycle (Kolb 1984) (Figure 9.1).

Figure 9.1 The experiential learning cycle (Kolb 1984).