Mandy Gamble, BA, DipN.
Clinical Team Leader, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, LeicesterAll nurses will be familiar with the emotional and physical trauma of dealing with a cardiac arrest. It is almost inconceivable that anyone could walk away from such an incident and not be affected by it in some way, particularly if the resuscitation attempt has been unsuccessful.
All nurses will be familiar with the emotional and physical trauma of dealing with a cardiac arrest. It is almost inconceivable that anyone could walk away from such an incident and not be affected by it in some way, particularly if the resuscitation attempt has been unsuccessful.
Currently, the issue of debriefing is associated with high-profile incidents. Mitchell (1984) first considered debriefing following a critical incident. Concentrating mainly on emergency workers who had attended at the scene of an accident, he noted that personnel who attended debriefing sessions did not suffer the 'railroad effect' of accumulated stress, in which the stress is ignored and eventually manifests itself in the form of physiological or psychological damage. However, there have been claims that incorrectly performed debriefing can do more harm than good (Coombes, 1988).
Aims of the study
The study was designed to identify whether a debriefing process after a resuscitation attempt on a patient following a cardiac arrest reduced the degree of stress generated by dealing with both the physical and psychological demands of the situation. The nurses were also asked to reflect on the incident to try to identify any learning needs.
Nurses from a large medical unit comprising a medical assessment unit, cardiac care unit and eight medical wards were invited individually or as a group to participate in a debriefing session as soon as possible after a cardiac arrest. They were asked to describe the experience and their feelings about it. The format of the debriefing process is shown in Box 1. This model was chosen because it acknowledges that there will be stress reactions, and that learning needs should be addressed. Moreover, this format has been specifically designed to deal with critical incident debriefing (Jimmerson, 1988).
Interviews during the semi-structured sessions were tape-recorded. Nurses led the discussion, although some initial direction was provided by the researcher. Following the transcription of the tapes, the issues raised by the nurses were identified. The nurses were asked to reflect on these and to identify learning needs.
Findings and discussion
Not surprisingly, the psychological aspects of a cardiac arrest tended to be at the forefront of the experiences described by the interviewees. Anxiety was exhibited by verbal and nonverbal means, with coping mechanisms ranging from sadness to laughter, or from emotional outpourings to detachment and indifference. The unpredictability of a cardiac arrest results in unique feelings for each individual.
Stress response - A call from another member of staff, the sound of the arrest buzzer or finding a patient in cardiac arrest will all trigger a stress response known as the 'general adaptation syndrome' (Box 2) (Selye, 1976). This stimulus-response syndrome triggers a wide-ranging set of bodily changes designed to ensure physical adaptation to an event.
Manderino et al (1986) demonstrated increased pulse rate and blood pressure during a simulation of a cardiac arrest. Emotional thoughts trigger the physiological response with which we are all too familiar. As one nurse in the study put it:
'I felt the usual adrenaline rush.'
Most physiological responses to stress are well within functional limits and, in the case of responding to a cardiac arrest, are a necessity in order to be able to deal with the event at the time. An interesting finding in this study was that, although most of the nurses recognised the 'adrenaline rush', few were perturbed by it: it was generally accepted as a vital part of the resuscitation attempt. However, shaking, fumbling and dropping things was not associated with an adrenaline rush but seen as a lack of practical and manual skills.
Sources of stress - Sources of stress for nurses include work overload, the erratic nature of the work and frequent deaths (Hipwell et al, 1989). Farrington (1995) goes further, adding that working against the clock, having no second chance to do things and sudden swings between quiet times and great activity all produce stress. All of these experiences may be part of a resuscitation attempt.
Emotional response - Whether or not the nurse knows the patient has a dramatic effect on how he or she will respond to the cardiac event (Tanner et al, 1993). In the interviews in the study, reference was made to whether or not the nurse knew the patient involved. Generally, resuscitation attempts and the outcome were accepted and coped with better if no relationship had been developed.
When nurses had been involved in the care of a patient and had acted as an advocate on his or her behalf, there was a deeper meaning attached to the outcome. Intense sadness emerged as a result of a resuscitation attempt that did not comply with the patient's or family's wishes; one nurse said:
'The resuscitation attempt was ridiculous. He wouldn't have wanted it.'
Menzies (1960) suggested that socialisation into nursing fosters the expectation that nurses will control their feelings, with emotional outbursts seen as failure to cope. Although this view may appear outdated, a more recent study by Spencer (1994) confirmed that 29% of nurses bottle up their emotions. Despite this, Finlay and Dallimore (1991) found that relatives gained great support from being aware that the staff member was upset following a resuscitation attempt, while staff who appeared colder and more business-like tended to cause offence.
To respond emotionally by crying or feeling sad following a patient's death is sometimes deemed to be inappropriate. In the study, emotions manifested themselves as euphoria, increased activity or intense sadness. One nurse described her experience:
'Afterwards I just went manic, trying to do everything at once. I did keep feeling emotion welling up and was trying to push it back down.'
Laughter - This may seem an unusual response in such circumstances, but is quite usual. Laughter was apparent in almost all of the interviews. It was used to break up descriptions of particularly harrowing aspects of the resuscitation attempt and may be linked to a nervous response:
'I couldn't get to the patient for equipment' (laughing)
Laughter is a way of coping with 'cognitive dissonance' (Zijderveld, 1983), perhaps in this case between the reality of everyday and ideal practice. Laughter helps people to master situations over which they have no control. Sometimes this may seem inappropriate but it is a useful method to break down barriers and tension. The interviews revealed a lightheartedness on the nurses' part about the fact that the arrest team had been disorganised, that the arrest had been unexpected and that there was relief when it was all over. Once the nurses realised their feelings were shared, they felt more at ease with each other.
Laughter has a major role to play following a resuscitation attempt, whatever the outcome. It allows nurses to 'test the water' on their emotional responses.
Guilt - A cardiac arrest, and subsequent death, represent the negative side of nursing rather than the positive (Kiger, 1994). Guilt in some form was expressed by all the nurses in this study. Guilt was manifested for a number of reasons; for example, because of a perceived lack of personal or group clinical skills; because a relationship had been built up with the patient after in-depth advocacy; because of doubts about whether it was ethical to resuscitate; or because of deep emotions arising from the death:
'I felt how I usually feel with futile arrest calls. I felt sad that his family couldn't be with him when he died.'
The importance of acknowledging feelings of guilt is examined during the teaching phase of the debriefing model. However, some individuals may require further specialised counselling, and need to be provided with relevant information should they wish to pursue this issue.
Leadership - O'Donnell (1990) pointed out how much confusion takes place during an resuscitation attempt as staff struggle with which role to take, with many swapping and changing roles throughout.
There was evidence of reduced stress, however, when a recognised team leader was appointed:
'It's always really nice to have that one person, in this instance it was the senior house officer, to take control, lead the arrest and keep calm. It kept everyone else calm.'
Experiential learning - Nurses must recognise their basic needs and requirements if they are to understand their responses to an event such as a resuscitation attempt.
Experiential learning theory has become central to nursing expertise in recent years. Its uptake within the nursing curriculum has emphasised that work experience, and indeed learning in the workplace, is central to vocational education.
However, it is important to realise that, while every situation is a potential learning situation, we do not necessarily learn from everything we do or everything in which we are involved. Some sort of cognitive process is required: we need to notice what we do and be aware of what is happening. The experience has to be brought into conscious awareness if learning is to take place (Henry, 1989). The ways in which future situations are experienced depend on the ability of the individual to transform present experience into knowledge, skills, attitudes, values and emotions (Jarvis, 1987).
Shared reflection can lead not only to individual change, but also to group change, a relevant factor in this case, as resuscitation is a team effort. Thus, by reflecting on our knowledge and practice in the company of others, we are able to modify our ideas and beliefs about the world in a way that we never could if we were alone.
Reflection is vital both for learning by experience and for developing new skills, for it highlights patterns of action and intuitive performance, so enabling people to assess how they respond to a situation (Jarvis, 1991). New insights and ideas are then applied to future situations and reflected on, leading to reflective knowledge.
Page and Meerabeau (1996) showed that, by acknowledging their feelings and experiences about a cardiac arrest and subsequent resuscitation, nurses are able to enhance personal knowledge by utilising the experience. Moreover, through reflective practice they can reveal and understand the feelings and attitudes that shape their personality and behaviour. These are essential for the development of practice. Reflection upon practice is an essential precursor to nurses collaborating and sharing their knowledge and experience. In this study, the act of reflection enabled the nurses to know what they would do differently in future and to realise what they had learned and what they needed to learn. One nurse described an aspect of resuscitation with which she felt she would be unable to cope:
'I don't think I'd be very good at the drugs because I'd be too caught up on what was going on, rather than looking at my watch.'
Recollections of previous arrest scenarios were identified in all cases, indicating that memory plays a large part in experiential learning. The memory of having gone through the experience before increases confidence. This is emphasised in a study by Whiteley et al (1987) where confidence was linked to experience.
During all the interviews, the experienced nurses talked about how they felt about a situation, whereas those who were less experienced displayed concern about their level of knowledge. Thus once manual skills and a knowledge base have been established, nurses focus on a broader aspect of the resuscitation attempt.
Experienced staff gave their attention to the needs of relatives, other patients and staff, while still playing an active part in the resuscitation. Benner (1984) recognised this transformation and relates it to the acquisition of nurses' knowledge through experience by the use of reflective practice.
In this study, the inexperienced nurses were able to gain a great deal from experienced colleagues at the time of the arrest regarding direction and learning opportunities. In the debriefing session, emotions could be voiced and shared. This form of reflective practice has been shown to enhance skills and develop teamwork, as inexperienced nurses hear their more experienced counterparts own up to having emotional feelings, too (Box 2). More importantly, the inexperienced nurses realised that it is acceptable to have such feelings (Jimmerson, 1988).
This study found that nurses, particularly those who are inexperienced, benefit from a debriefing session following a cardiac arrest. There is a need to acknowledge this and to ensure that opportunities are given to debrief the team following a resuscitation attempt. Without debriefing, nurses may not know they have been affected by the experience nor will they have the opportunity to identify learning needs. Evaluating the effects of stress and the coping mechanisms necessary leaves little doubt that cardiopulmonary resuscitation is one of the most stressful situations with which a nurse has to deal. It is not enough to acknowledge that high stress levels can be detrimental. There needs to be acknowledgment of individual responses and counterbalancing of them with constructive learning opportunities.
Further research is needed to identify the after-effects of a resuscitation attempt. Senior staff should be encouraged to use listening, counselling and teaching skills to create an atmosphere of understanding and acceptance for each nurse. Managers should promote the ethos that support is for everybody, and that needing support is not an admission of weakness. Nurses' identified needs can then be used to develop learning programmes.
Debriefing is supported by the Resuscitation Council in its Guidance for Clinical Practice and Training in Hospitals (Gabbott et al, 2000) as being a means of facilitating audit and reporting of standards while allowing staff time to reflect on their experience.
The success of debriefing will depend on the individual perceptions of the staff involved, the expertise of the group facilitator and whether the identified learning needs are addressed. However, the art of turning a negative experience into a positive one is lost if the debriefing is not carried out as soon as possible following the arrest, as time may distort memories of past experiences (James, 1997).
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