Critical Incident Stress Debriefing in the ICU; Feasibility, Usability and Satisfaction

Critical incident stress debriefing (CISD) is a method of stress management that has been used in military, police, fire, and frontline personnel since the 1980s. The purpose of CISD is to help workers in these fields debrief and manage stress that can arise in their jobs due to critical incidents. A critical incident can be described as an event that happens suddenly and that disrupts a person's feeling of control in their surroundings. If not managed appropriately this stress can lead to more serious conditions such as post-traumatic stress disorder (PTSD), thus the aim of CISD is to prevent unmanaged stress leading to serious problems. CISD can be adapted and used in healthcare settings but is underutilized. Healthcare workers, especially those that work in Intensive Care Units (ICU) are frequently exposed to critical incidents. The underutilization of CISD can put ICU workers at higher risk of developing undesirable consequences of mismanaged stress. At a local tertiary hospital, no guideline for CISD exists in an ICU. The purpose of this project was to create a guideline that would allow ICU staff to hold debriefing sessions in their unit following critical incidents. This was accomplished by the following objectives: 1) A guideline was developed that ICU staff could utilize for CISD in their unit, 2) The guideline was presented to key stakeholders in the ICU, 3) The guideline was revised after feedback was obtained from stakeholders of the ICU, 4) The feasibility, usability and satisfaction of the CISD guideline was evaluated by a survey that was provided to 30 ICU staff, 5) The project details were disseminated to a broader audience. The literature shows that there is significant underutilization of CISD in healthcare settings. There are many barriers to CISD in healthcare settings including timing of the debriefing, when to hold a session, and who leads the session. The project was implemented and evaluated in a series of steps. The first was to create a guideline. After the guideline was developed and approved it was presented to key stakeholders of the ICU. In the meeting, ideas for implementation of the guideline were discussed. Feedback was obtained on how stakeholders supported the guideline, and how they would like to see the guideline fit into the unit workflow. The feedback from stakeholders prompted minor revisions to the guideline. The guideline was then shared with 30 ICU staff. After staff had the opportunity to become familiar with the guideline a survey was provided evaluating staff perceptions of the feasibility, usability and satisfaction of the guideline content. The final objective of the project was to gather details about the project and disseminate those details to a broader audience at a nursing education conference. The survey response rate was 80% (24/30). Of the 24 responders, 58% (14/24) felt the guideline would be feasible for their unit; 79% (19/24) felt the guideline would be usable; and 71% reported they were "very satisfied" with the guideline content. Barriers included: timing of the intervention, lack of debriefing by a professional, consistency of intervention implementation. Facilitators reported were: a perceived benefit for new staff, method to increase communication, the follow up call/text will close the loop, trial and error period can improve the processes. Further study could be conducted to assess whether or not use of a debriefing guideline leads to decreased stress, increased job satisfaction and higher quality care delivery in the ICU.

Running Head: CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 1 Critical Incident Stress Debriefing in the ICU; Feasibility, Usability and Satisfaction Erick Howe University of Utah College of Nursing In partial fulfillment of the requirements for the Doctor of Nursing Practice Executive Summary Critical incident stress debriefing (CISD) is a method of stress management that has been used in military, police, fire, and frontline personnel since the 1980s. The purpose of CISD is to CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 2 help workers in these fields debrief and manage stress that can arise in their jobs due to critical incidents. A critical incident can be described as an event that happens suddenly and that disrupts a person's feeling of control in their surroundings. If not managed appropriately this stress can lead to more serious conditions such as post-traumatic stress disorder (PTSD), thus the aim of CISD is to prevent unmanaged stress leading to serious problems. CISD can be adapted and used in healthcare settings but is underutilized. Healthcare workers, especially those that work in Intensive Care Units (ICU) are frequently exposed to critical incidents. The underutilization of CISD can put ICU workers at higher risk of developing undesirable consequences of mismanaged stress. At a local tertiary hospital, no guideline for CISD exists in an ICU. The purpose of this project was to create a guideline that would allow ICU staff to hold debriefing sessions in their unit following critical incidents. This was accomplished by the following objectives: 1) A guideline was developed that ICU staff could utilize for CISD in their unit, 2) The guideline was presented to key stakeholders in the ICU, 3) The guideline was revised after feedback was obtained from stakeholders of the ICU, 4) The feasibility, usability and satisfaction of the CISD guideline was evaluated by a survey that was provided to 30 ICU staff, 5) The project details were disseminated to a broader audience. The literature shows that there is significant underutilization of CISD in healthcare settings. There are many barriers to CISD in healthcare settings including timing of the debriefing, when to hold a session, and who leads the session. The project was implemented and evaluated in a series of steps. The first was to create a guideline. After the guideline was developed and approved it was presented to key stakeholders of the ICU. In the meeting, ideas for implementation of the guideline were discussed. Feedback was obtained on how stakeholders supported the guideline, and how they would like to see the guideline fit into the unit workflow. The feedback from stakeholders prompted minor revisions to the guideline. The guideline was then shared with 30 ICU staff. After staff had the opportunity to become familiar with the guideline a survey was provided evaluating staff perceptions of the feasibility, usability and satisfaction of the guideline content. The final objective of the project was to gather details about the project and disseminate those details to a broader audience at a nursing education conference. The survey response rate was 80% (24/30). Of the 24 responders, 58% (14/24) felt the guideline would be feasible for their unit; 79% (19/24) felt the guideline would be usable; and 71% reported they were "very satisfied" with the guideline content. Barriers included: timing of the intervention, lack of debriefing by a professional, consistency of intervention implementation. Facilitators reported were: a perceived benefit for new staff, method to increase communication, the follow up call/text will close the loop, trial and error period can improve the processes. Further study could be conducted to assess whether or not use of a debriefing guideline leads to decreased stress, increased job satisfaction and higher quality care delivery in the ICU. Special thanks go to the project committee, which include the Project chair, Nancy Allen, PhD, ANP-BC; Adult-Gerontology Acute Care Nurse Practitioner specialty track director Denise Ward, DNP, ACNP-BC, FNP-BC; Assistant Dean of MS and DNP programs, Pamela Hardin, PhD, RN, CNE; and project Content Expert, Teri Flint PHD, LCSW. CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 3 Table of Contents Executive Summary……………………………………………………………………………………….2 Acknowledgements ……………………………………………………………………………………….5 Introduction………………………………………………………………………………………………..6 Problem Statement…………………………………………………………………………………6 Clinical Significance……………………………………………………………………………….7 Purpose and Objectives…………………………………………………………………………….8 Literature Review…………………………………………………………………………………………9 Introduction………………………………………………………………………………………...9 CISD Background………………………………………………………………………………….9 PTSD……………………………………………………………………………………………...10 CISD in practice among healthcare professionals………………………………………………..11 Nurse Practitioner Roles………………………………………………………………………….12 Conceptual Model………………………………………………………………………………………..13 Implementation and Evaluation Plan…………………………………………………………………..15 Implementation and Evaluation………………………………………………………………………...16 Objective 1………………………………………………………………………………………..16 Objective 2………………………………………………………………………………………..17 Objective 3………………………………………………………………………………………..17 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 4 Objective 4………………………………………………………………………………………..18 Objective 5………………………………………………………………………………………..19 Results…………………………………………………………………………………………………….19 Recommendations………………………………………………………………………………………..22 Doctor of Nursing Practice Essentials……………...…………………………………………………...23 Essential V………………………………………………………………………………………..24 Essential VII………………………………………………………………………………………24 Conclusion………………………………………………………………………………………………...25 References…………………………………………………………………………………………...……27 Appendices ……………………………………………………………………………………………….29 Appendix A: DNP Project Proposal PowerPoint…………………………………………………29 Appendix B: Institutional Review Board Exemption…………………………………………….37 Appendix C: Stakeholder PowerPoint Presentation……………………………………………...39 Appendix D: ICU Staff Educational Handout……………………………………………………46 Appendix E: ICU Staff Survey…………………………………………………………………...49 Appendix F: Final DNP Project Poster…………………………………………………………...52 Appendix G: Snowbird CME Conference Abstract………………………………………………54 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU Acknowledgements First and foremost, I must thank my amazing family; my incredible wife, our parents and everyone else that took time out of your busy lives to help me get through this by working full time, watching our son, and always being willing to lend a helping hand in so many ways. I couldn't have done this without you. Thank you. Thank you to the RICU staff for being willing to learn with me through this project, finding ways to better care for ourselves and in turn provide better care to our patients. Thank you to Nancy Allen for all of your feedback, support and encouragement through this process. Thanks to Denise Ward for your encouragement and support through the entire three years of the program. 5 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 6 Critical Incident Stress Debriefing in the ICU; Feasibility, Usability and Satisfaction Problem Statement Intensive care unit (ICU) staff are often exposed to traumatic and difficult situations in their day to day work. Mitchell, Sakraida and Kameg (2003) defined a critical incident with the following statement: "Extraordinary events that happen suddenly, without warning, and disrupt a person's feeling of control and faith in their surroundings are referred to as critical incidents." Unexpected codes such as cardiac or respiratory arrests, workplace violence, difficult interactions with patients and families, and other difficult situations that occur daily in the ICU fit under this definition. There is a large amount of literature that has been conducted on critical incident stress debriefing (CISD) in front line personnel such as firemen, police officers, EMS, and even emergency department staff, but very little research has been conducted on inpatient hospital staff. One study (Everly, Flannery, & Eyler, 2002) showed that if stress that arises from critical incidents is not addressed, the stress can accumulate and can potentially cause symptoms of post-traumatic stress disorder (PTSD). Post-traumatic stress disorder is a problem that affects a wide range of the United States' population. At one time, a 3.5% prevalence of PTSD was reported among all populations combined in the US (Kessler et al., 2005). Narrowing the scope of PTSD to nurses, multiple studies have shown that the prevalence of PTSD among nurses ranges from 9% to 33% (Laposa, Alden, & Fullerton, 2003; Maunder, Lancee, &Balderson, 2006; Ricther & Berger 2006; Battles, 2007; Dominguez-Gomez & Rugledge, 2009). Cumulative stress can lead to burnout in staff which can lead to poor job performance, absenteeism, and decreased quality of care delivered to patients (Gunusen & Ustun, 2010). With up to 33% of nurses struggling with PTSD symptoms, it must be considered that other professionals in different disciplines working in the ICU struggle CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 7 with PTSD symptoms as well. This is a problem because the compounding effects of unaddressed stress can lead to overall poor care that is delivered to patients in the ICU. Currently at a large metropolitan medical center in Salt Lake City, the respiratory ICU (RICU) does not have guidelines for helping staff debrief after critical incidents occur. The goal of this project is to formulate a guideline based in evidence about CISD for the staff of the RICU to utilize after critical incidents occur in their unit. Barriers that will be assessed during the guideline development will include when it is most appropriate to debrief, what support will be given from the unit to implement a successful guideline, who will lead the debriefing sessions, and how long the sessions should be. Clinical Significance Critical incidents that lead to PTSD among nurses is high. ICU nurses are specifically at greater risk of developing PTSD symptoms when compared to general nurses (Mealer, Shelton, Berg, Rothbaum, & Moss, 2007). Due to the fact that ICU nurses are exposed to a high-stress environment the rates of PTSD symptoms are approximately 24%-29% among ICU nurses compared to approximately 14% among general nurses (Mealer et al., 2007). Burnout, lack of job fulfillment, and stress associated with work makes the ICU a difficult place to maintain staff. There are many vacancies among ICU jobs when compared to other specialties of nursing (Mealer et al., 2007). If nurses and ICU staff are unable to cope with the stresses of their day to day responsibilities, they are at increased risk of developing PTSD (Mealer et al., 2007). Stakeholders for this project include administrators, unit manager/supervisor, the nurses and staff of the RICU, and employee assistance workers. Administrators should be interested in a debriefing guideline due to the fact that retaining nurses at the bedside, especially in an ICU is CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 8 difficult. Patient safety is increased when experienced nurses stay at the bedside. When staff turnover is high, it is difficult to deliver quality care. A guideline for debriefing will allow ICU staff to better manage stresses associated with their jobs. This better stress management will help keep ICU nurses in their jobs longer, creating a more cohesive unit capable of delivering high quality care to patients. The nursing manager of the RICU should be involved for similar reasons to administrators. With better stress management among his employees, job satisfaction will be higher, leading to increased staff retention and better team work. Staff will benefit from the guideline as it is their mental health that will benefit. Having healthy ways to deal with stressors from work will increase job satisfaction and staff engagement. Employee assistance workers are another group of stakeholders that are important in helping to provide debriefing strategies and further assistance employees may need after debriefing. The current practice for employees at the metropolitan medical center to get help with any problems resulting from their work is to visit with an employee assistance program (EAP) representative. Employee assistance can be a great program to help workers through difficult situations related to work. However, in general, EAP does not adequately address the stress due to cumulative effects of critical incidents experienced by ICU staff. Employees have to seek EAP for assistance and go out of their way to get help. A guideline that staff could initiate in their unit could help start the process for debriefing after critical incidents occur. This could be instrumental in decreasing the prevalence of PTSD symptoms among ICU staff. Purpose and Objectives The purpose of this project is to develop a guideline that will allow ICU staff members to hold debriefing sessions in their unit following critical incidents. CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 9 The objectives for the project are: 1. Develop a guideline which ICU staff can utilize for debriefing 2. Present the guideline to key stakeholders 3. Revise the guideline after feedback from stakeholders 4. Evaluate the usability, feasibility, and satisfaction of the CISD guideline 5. Disseminate project details to a broader audience Literature Review Introduction Critical incident stress management or debriefing (CISD) is a concept that has been used since it was first introduced in the early 80's. It is designed to help alleviate stress among workers that work with or are exposed to traumatic events (Mitchell, Sakraida, & Kameg, 2003). There is a large amount of literature explaining the benefits of CISD among frontline personnel, but sparse research exists pertaining to CISD use by inpatient hospital workers, specifically Intensive Care Unit (ICU) staff. Literature shows that there is an increased prevalence of PTSD symptoms and depression among nurses, especially critical care nurses. Subjects that will be addressed in this portion of the literature review will include; CISD background, prevalence of PTSD in the general population, prevalence of PTSD among nurses with focus on critical care nurses, the limited and underutilized use of CISD among hospital workers, and nurse practitioner roles in debriefing sessions. CISD Background CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 10 Critical incident stress debriefing has been around since the early 80's and is used by a variety of workers in different fields to help deal with stressful events (Mitchell et al., 2003). Mitchell et al. (2003) stated that the goal of CISD is to alleviate the impact stressful or traumatic events have on a person. The goal of CISD is to help manage stress that results from a traumatic event early, typically between 24 and 72 hours after the event, so as to not allow the stress to cause longstanding problems (Mitchell et al., 2003). In a healthcare environment, such as an ICU, a full CISD session 24-72 hours post incident may not always be feasible due to staff not always being at work on consecutive days. However, there are a variety of different modalities whereby CISD can be accomplished. Since time constraints in an ICU are likely a large barrier to a full and complete CISD session, emotional diffusing is a tactic that is part of CISD that can be held within 24 hours after a critical incident. The goal of emotional diffusing is to assess the incident and the immediate effect it may have on an employee (Blacklock, 2012). This is an informal part of an overall CISD process with the goal of assuring staff wellbeing and ability to finish a shift after a critical incident (Blacklock, 2012). Adaptations to CISD can be successful and should be considered when putting together a guideline or protocol for inpatient staff usage (Blacklock, 2012). PTSD Post-traumatic stress disorder is a national problem that can be accompanied by very serious signs and symptoms. Drawing on research done by Lavoie et al., (2016) and MullerLeonhardt, Mitchell, Vogt & Schurmann (2014), important symptoms associated with PTSD include: • • Re-experiencing the traumatic event that lead to critical incident stress; Anxiety; CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU • • • • • • • • 11 Aggressiveness; Loss of sleep; Difficulty making decisions; Experiencing feelings of helplessness; Autonomic hyperactivity; Increased amount of sick days; Decreased job satisfaction Decreased job performance; Lavoie et al. (2016) examined prevalence of PTSD among nurses compared to the general public. The authors stated that in a study of over 9,000 Americans among "all" populations, the prevalence of PTSD was 3.5% (Lavoie et al., 2016). The same authors shared that among nurses, the rate of PTSD was anywhere between 9% and 33% (Lavoie et al., 2016). Another study was conducted where the question was asked if ICU and critical care nurses had a higher prevalence of PTSD symptoms and depression than did general nurses (Mealer et al., 2007). The findings of the study indicated that there was indeed a higher prevalence of PTSD symptoms among ICU nurses when compared to the prevalence of PTSD symptoms in general nurses (Mealer et al., 2007). Another finding of this study by Mealer et al. (2007) stated that up to 20% of ICU nurses had symptoms of anxiety and up to 30% of them had symptoms of depression. CISD practice among healthcare professionals There is relatively little information and research about CISD use among healthcare professionals. In an article written by Muller-Leonhardt, Mitchell, Vogt and Schurmann (2014), the need for a debriefing program in healthcare settings is discussed. The authors shared that there should be a management program available for not only the large and obviously stressful events that occur in the hospital, but also for smaller, "near misses" that occur on more of a day to day basis. The authors further discussed how implementing a CISD guideline or program into CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 12 a complex system like a hospital system takes time. They stated that care should be taken to individualize a program to best fit the needs of the system (Muller-Leonhardt et al., 2014). The use of CISD in hospital settings is very underutilized. In a study of Australian hospitals, 69% of those surveyed did not have a guideline for CISD after critical incidents occurred in their emergency departments (Wuthnow, Elwell, Quillen, & Ciancaglione, 2016). Wuthnow et al (2016) also shared that 90% of individual units in those hospitals surveyed did not have guidelines for CISD. Blacklock (2012) also stated that it is imperative to have guidelines and strategies that will help to retain staff after these critical incidents occur. Nurse Practitioner Roles Nurse practitioners (NPs) that work in ICUs are in a unique spot to help guide and lead a debriefing session after a critical incident occurs. In an article discussing early identification of critical incident stress, Cain and Ter-Bagdasarian (2003) discussed the role of the NP in debriefing. Nurse practitioners are educated to lead within a healthcare environment (Caine & Ter-Bagdasarian, 2003). Furthermore, the authors stated that this leadership can be used by the NP in an ICU as they have training in advanced communication techniques. This training is important in helping to conduct a debriefing session and the NP is a leader that can help accomplish effective stress management in the ICU. Caine and Ter-Bagdasarian (2003) also stated that once stress is acknowledged and recognized critical care nurses can learn how to prevent cumulative effects of critical incidents. The NP is a vital team member to successful debriefing and can help other ICU staff learn and recognize triggers for stresses after critical incidents. CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 13 Conceptual Model There are a number of models, frameworks, and theories that can guide system change at organizational levels. The model that was used to guide this debriefing guideline creation project was the Organizational and Systems Change Model (OSCM). The ICU debriefing guideline challenged the current culture of the RICU. The current practice in the RICU had no formal process, protocol, or guideline for staff to debrief after a critical incident occurred in the unit. The four components of the OSCM that guided this project included; 1) Gaining an understanding of the current system, 2) Establishing shared goals of the proposed change, 3) Identifying barriers to the change, 4) Involving the organization and stakeholders during the process (Edberg, 2007). This model guided the creation of the debriefing guideline in all stages of the process as outlined below. The first goal was to meet with key stakeholders including the ICU nurse manager, medical director, and the content expert to discuss the project background and significance. The current practice regarding debriefing after critical incidents was examined and a shared understanding of that practice was established. This step in the guideline development was important and gave those that were helping to create the guideline a place to begin. Since there was no formal debriefing guideline in place, education about the prevalence of critical incident stress was needed so ICU stakeholders understood the importance of the proposed guideline. After the current practice was understood, goals were established for the debriefing guideline. The goals of the guideline included holding a short ten to fifteen-minute debriefing period after a critical incident occurs in the ICU. The goal was that either a nurse practitioner, charge nurse, or unit social worker would lead the debriefing sessions after they were properly trained. The goal of the guideline was to establish a safe environment where debriefing could be CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 14 used to assess what happened, what the team did well during the incident, and ways the team could improve the next time a similar incident occurs. An informal follow up that would occur 24 hours later is also an important aspect of this guideline. This may take place in the form of a call, or a text message from the nurse manager to ensure all individuals involved are handling the stress from the incident appropriately. This informal part of the guideline required discussion with key stakeholders, and it was felt that the nurse manager was the appropriate person to fulfil this portion of the guideline. After goals were agreed upon, barriers were discussed. The OSCM included discussing barriers with stakeholders and was an important component in successfully implementing change. One barrier that was identified was proper training of those that would lead the debriefing session. Training the unit nurse practitioners, charge nurses, or social workers will still need to occur prior to implementation of the guideline. The content expert for this project suggested that this training could be done through simulation training. Other barriers that were addressed included: When does the debriefing take place? How long after the incident should the debriefing begin? Where will the debriefing occur? The answers to these questions were discussed with stakeholders, but the proposed answers to these questions prior to discussion included: 1) Debriefing will occur within the shift that the incident happened on. 2) The sessions should take no more than 15 minutes as patient care is still occurring during the debriefing session. 3) The debriefing should take place in a quiet, comfortable room which will likely be the unit rounds room. Discussing barriers with key stakeholders was a key portion of the guideline formation and as a key component of the implementation phase of this project. Key stakeholders were involved throughout the process of the guideline creation. Stakeholder involvement is an important aspect of the OSCM and helped to ensure a feasible 15 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU guideline was created. The purpose of the guideline was to improve the overall health and wellbeing of ICU staff by decreasing stress that can lead to PTSD. By involving stakeholders in the project, they took ownership of the changes to unit culture which should help to ensure successful guideline implementation. Implementation and Evaluation Plan Table 1. Project Objectives and Related Implementation and Evaluation Plan Objective 1. Develop a guideline which ICU staff can utilize for CISD Implementation • • • 2. Present the guideline to key stakeholders • • 3. Revise the guideline after feedback is obtained from stakeholders • • • • Evaluation Submitted application for IRB Created a framework of the debriefing guideline which was informed by content expert and evidence based literature Contacted key stakeholders in the ICU about the project • Created an informative power point presentation for stakeholders detailing guideline Delivered power point presentation to stakeholders • Feedback obtained in meeting with stakeholders Incorporated stakeholder feedbacks Established guideline details Prepared guideline for stakeholder implementation • • • • • • IRB exemption provided to project chair Guideline developed Guideline approved by project chair and content expert Stakeholder meetings held Power point presentation for stakeholders reviewed by content expert and approved by project chair Power point presented to stakeholders Feedback discussed with project chair, approval of changes obtained Guideline presented to ICU stakeholders for implementation at their discretion 16 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 4. Evaluate the feasibility, usability, and satisfaction of the CISD guideline • • 5. Disseminate project details to a broader audience • • • Created survey assessing ICU staff's perception of feasibility, usability and satisfaction of guideline Distributed to staff by hard copies on unit • Project details were compiled Developed an abstract for submission to a conference Submitted the abstract • • • Survey approved by project chair Answers compiled and analyzed, shared with project chair Results shared with ICU stakeholders Poster abstract approved by project chair Implementation and Evaluation Objective 1: Develop a guideline which ICU staff can utilize for Critical Incident Stress Debriefing (CISD) Following the project PowerPoint presentation to the University of Utah College of Nursing faculty of the project (see Appendix A), approval was granted to proceed with the project. An IRB application was submitted to the appropriate health care system and IRB exemption was granted (See Appendix B). After a meeting with the content expert, a guideline was developed. The literature review continued to inform the guideline development and was updated as the project advanced. The guideline consisted of background information of the effects of critical incident stress, PTSD prevalence in ICU nurses, and evidence based debriefing strategies. After the initial meeting was held with the content expert the guideline evolved, a Power Point presentation was created detailing CISD and the benefits of constructive stress management (see Appendix C). The power point was finalized, approved by the content expert and project chair, and was prepared to share with key stakeholders involved with the project. CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 17 Evaluation of objective one was completed by ensuring the afore mentioned implementation steps were completed in a timely matter. These evaluations occurred with the help of the project chair as well as the content expert. The short power point presentation that was presented to stakeholders was approved by project chair. Objective 2: Present the guideline to key stakeholders The meeting with key stakeholders including RICU manager, medical director, leadership council, NPs and RNs took place after the project presentation to the CON occurred. In the meeting with stakeholders, the goal of introducing a debriefing guideline was completed. The importance of constructive stress management and recognizing signs and symptoms of PTSD was described. ICU staff were then educated about the guideline with a one page handout detailing the guideline (see Appendix D). Evaluation of objective two involved the project chair and content expert and their approval of the short power point presentation that was delivered to stakeholders (Appendix C). This objective was considered the implementation phase for this project as stakeholders were made aware of the goal of the project, and ICU staff were educated about the guideline. The feedback from stakeholders would then be used to make revisions to the guideline. Objective 3: Revise the guideline after feedback is obtained from stakeholders and ICU staff to help them take ownership of the guideline This objective included gathering feedback from the ICU staff and stakeholders. Roles of who will guide the debriefing sessions were considered. It was decided by unit stakeholders that nurse practitioners, charge nurses, or preferably unit social workers on the unit at the time of the incident will help to run the debriefing sessions. Social workers were suggested as they likely CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 18 would not have been directly involved in an incident regarding patient care. It was felt that they may offer a good outside source to guide productive, safe, and educational discussions during the emotional diffusing portion of the guideline. Due to timing of the incident, social workers may not always be available to help lead the session. In that case, it would become the responsibility of the nurse practitioner or charge nurse that was trained to lead the session. The timing of the guideline was established. Debriefings will occur during the shift an incident occurs, preferably before shift change. The location of the debriefing sessions will take place in the unit rounds room. Evaluation of objective three were achieved by ensuring feedback from stakeholders was obtained in time to make changes and that the proposed changes still complied with evidenced based practice. The revised guideline was then approved by the content expert and project chair to ensure the guideline still met criteria for use. Objective 4: Evaluate the feasibility, usability, and satisfaction of the CISD guideline The purpose of this objective was to assess the ICU staff's perceptions of the guideline with a short survey (see Appendix E). Since they are the individual's that will benefit from the guideline their support is important. The survey was brief with questions asking about perceptions of feasibility, usability and satisfaction with the guideline content. Simple demographics like level of education and gender were recorded. Age was also recorded and was reported as a mean with standard deviation. The answers to the survey were provided to the ICU stakeholders and can be seen later in this paper in the "Results" portion. This objective was evaluated by forming the survey and obtaining approval of the survey from the project chair. The survey was distributed by handing out 30 copies to staff after a short CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 19 introduction to the guideline was given. The answers to the survey were compiled and shared with the stakeholders. The complete breakdown of the answers that were given by ICU staff can be read in the "results" section later in this paper. In brief, the majority of ICU staff surveyed felt the guideline would be feasible, usable, and were satisfied with the content. Objective 5: Disseminate project details to a broader audience Dissemination of this project was important as the benefits of having a debriefing guideline for inpatient staff will be extremely helpful. First, a poster was made and presented as part of the Doctor of Nursing Practice (DNP) Scholarly Project course at the University of Utah DNP Poster Presentations (See Appendix F). The poster includes details about the cumulative effects of critical incident stress on nurses and inpatient staff and the potential to develop PTSD symptoms from poorly managed stress, the effects PTSD has on staff including feelings of burnout, and the process of formulating a debriefing guideline for ICU staff. Furthermore, the poster details the feedback from the ICU staff and the way these employees felt like the project could be beneficial in their unit. With the direction of the project chair, a poster abstract has been submitted to a conference for presentation. Evaluation of this objective came in the form of creating a successful poster for presentation as part of the DNP project course of the College of Nursing. An abstract for submission to a conference was also created. The abstract (see Appendix G) was approved by the project chair and submitted by the deadline for a local nursing education conference that will be held later this year. Results CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 20 As the project progressed, all components of objective one were completed. The guideline was created and meetings were held with key ICU stakeholders to make them aware of the project. Permission was granted to create the guideline and assess its feasibility in the unit. IRB officials at Intermountain Healthcare gave exemption for the project. The guideline was developed with input from the project content expert and evidence based literature. Objective two was completed by creating a power point presentation that was delivered to ICU stakeholders. The presentation was approved by the project chair. Objective three was completed during the presentation of the PowerPoint to ICU stakeholders. The feedback that was received from them was appreciated and was used to make minor revisions to the guideline. The details about who would lead the debriefing sessions, where the sessions would occur, and how long after an event they would occur was discussed. Nurse practitioners or charge nurses were chosen to lead the debriefing sessions, however, as discussed above, it was felt that an outside leader like social workers may be the best candidates to lead the debriefing sessions. The sessions are to last ten to fifteen minutes at a maximum. The sessions will take place during the shift that a critical incident occurs, if possible before shift change. Objective four was completed by handing out 30 surveys to ICU staff. Of those 30 surveys 24 were returned for a survey response rate of 80%. The average age of those participating in the survey was 33.3 years (±6.43 years) old. The education level of those that returned surveys ranged from some with no college education to MD, with 58% (14/24) of the respondents holding a bachelor's degree of science in nursing. The complete survey results were as follows: CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 21 The results for question one showed that 0/24 staff felt the guideline would not be beneficial, 4% (1/24) of staff felt the guideline would be somewhat beneficial, 25% (6/24) of staff felt the guideline would be beneficial, and 71% (17/24) stating it would be very beneficial. Question two results showed that 0/24 staff were very dissatisfied with the guideline content, 8% (2/24) of staff were somewhat dissatisfied with the guideline content, 4% (1/24) of staff were neither dissatisfied or satisfied with the guideline content, 17% (4/24) of staff were somewhat satisfied with the guideline content, and 71% (17/24) of staff were very satisfied with the guideline content. Question three showed that 0/24 staff felt the guideline would not be feasible, 42% (10/24) of staff felt it would be somewhat feasible, and 58% (14/24) felt the guideline would be very feasible in the ICU. Question four was an open-ended question that asked for suggestions about what the staff member felt would help the guideline be feasible in the ICU. Responses all centered around making time for the debriefing sessions and having consistency with the debriefing sessions once the guideline is implemented. Question five showed that 0/24 staff felt the guideline would not be usable, 21% (5/24) of staff felt the guideline would be usable, and 79% (19/24) staff felt the guideline would be very usable in the unit. Questions six and seven addressed what barriers and facilitators staff members felt would be key to the guideline implementation. Question eight was open ended for any suggestions or comments. Some common barriers to successful guideline implementation that staff shared CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 22 included: lack of time in the workday, lack of a professional facilitator for the debriefing sessions, and consistency of implementation. Staff felt that if a debrief was held for one incident but not another the routine use of the guideline would not become part of the workflow of the unit. Staff shared common factors that would lead to successful use in the unit and those included: Staff buy-in, perceived benefit for new ICU staff, increased communication among team members, closed loop follow up 24 hours later, and a trial and error period during guideline implementation. Objective five was completed by creating and submitting an abstract to a local nursing education conference. The abstract has been guided and approved by the project chair. The poster was also presented at the University of Utah DNP poster presentation as part of the curriculum for the DNP scholarly project course. Recommendations This aim of this project was to create a guideline that could successfully be implemented in an ICU so that ICU staff could hold debriefing sessions in their unit. The feedback that was obtained from key ICU stakeholders and from ICU staff show that in this unit, it should be feasible to hold debriefing sessions according to the proposed guideline. Some of the interesting feedback that should be explored further is the addition of more individuals like social workers into the guideline details. Social workers are in the unit on a regular basis interacting with patients and their families. However, they typically are not involved in critical incidents on the unit, certainly not to the extent that the medical team is involved. This distance that they have from the medical team, while still being part of the team, could make them a valuable player in CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 23 helping to successfully implement this guideline. The inclusion of social work should be explored before the guideline is implemented for use. This project is the beginning step of a much more in-depth study that could be conducted over a few years' time. The effects of positive stress management that begins with a debriefing guideline could be studied. Markers such as staff job satisfaction, feelings of burnout, turnover rates etc. could be studied before and after guideline use. There is great potential here for a much more in-depth human research project where ICU staff are the subjects. Careful attention would need to be taken to ensure that patient care did not suffer during such a study. Other factors that could be studied with this project in the future is whether or not there are positive outcomes for the staff with job satisfaction, retention, feelings of team unity, and whether or not those outcomes impact the quality of patient care that is delivered in intensive care units. The potential for the project to be continued may not be the most appropriate for future DNP students as a study of this magnitude would likely need to take place over a few years. The timing for a DNP project likely wouldn't allow for adequate study time and data collection, however, a DNP student could certainly take the beginning steps to formulate the study and present the study to a unit that is willing to track the use of the guideline in an in-depth manner. Doctor of Nursing Practice Essentials The doctorate of nursing practice (DNP) essentials are core elements that are important in the preparation of doctorate level trained nurses (AACN, 2006). These essentials outline important elements that are intricate to successfully becoming a well-trained nurse practitioner. This project, which deals with creating a debriefing guideline for better stress management among ICU staff, focuses on two of the core essentials, essential V and VII. CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 24 Essential V: Health Care Policy for Advocacy in Health Care The goal of this project is to create a guideline that will be utilized by ICU staff to better their own health and well-being. Essential V of the AACNs doctor of nursing practice essentials concerns health care policy that advocates for health care. One of the components of this essential is that DNP prepared graduates will be able to effectively participate in project development that will benefit those involved in healthcare (AACN, 2006). The essential helps prepare DNP graduates to participate in policy creation at levels including institutional. This project is to create a guideline that advocates for the health and wellbeing of the ICU staff. This falls in-line with this essential that the guideline could eventually be adopted at a wider level in the health system and benefit more healthcare staff than just the ICU. Essential VII: Clinical Prevention and Population Health for Improving the Nation's Health The project to create a guideline for ICU staff fulfills this essential by improving the ICU staff's mental health by learning better stress management and debriefing tactics. The goal of the project is to prevent post-traumatic stress disorder (PTSD) that results from inappropriately managed and compounding stress. The AACN describes that essential VII promotes clinical prevention and population health among individuals, families, and populations such as occupational populations (AACN, 2006). The project for debriefing would address the individual and the occupational population of ICU staff. The prevention of PTSD is important for ICU staff, and tactics similar to the ones in this project could be an important tool in helping to decrease prevalence of PTSD among ICU staff. Essential VII will be an important aspect of CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 25 the project and will be a guide to assure that the project is fulfilling the essentials of DNP education. Conclusion Critical incident stress has many negative, cumulative effects when not dealt with in positive and healthy ways. ICU staff are frequently exposed to critical incidents that lead to critical incident stress. Currently, the use of CISD is underutilized in hospital settings. This is evidence by the numbers of ICU nurses that struggle with symptoms of PTSD, burnout, compassion fatigue, low job satisfaction, and high job turnover rates. The utilization of CISD may have positive effects and help ICU staff better learn how to manage stress that is related to their jobs. The purpose of this project was to create a guideline that would allow ICU staff autonomy to hold the short debriefing sessions after a critical incident occurs in their unit. Together with the help of the content expert and a literature review, a guideline was created. The guideline was then presented to certain key stakeholders of the ICU. Taking their feedback and input, the guideline was tailored to best fit into the workflow of the ICU, where time is always of the essence. Roles for the sessions were discussed and established, especially regarding the inclusion of social workers as leaders of the debriefing sessions, timing was determined, and the place was chosen where the sessions would occur. These short debriefing sessions fulfill the first portion of a formal debriefing known as emotional diffusing. The details were then established for how informal follow up would take place by the unit nurse manager, and how ICU staff requesting or requiring more assistance with critical incident stress could get appropriate help. CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 26 The survey yielded good participation (80% response rate). The responses to the questions about feasibility, usability and the satisfaction the staff had with the guideline were generally positive with what would appear to be good buy-in. The guideline will seemingly be received with positive feelings among the staff members. ICU staff buy-in is important in this project as participation in this guideline will benefit the participants, and they will get out of it what they put into it. Finally, the creation of this guideline is the first step into much more in-depth study that could occur. The mental health of ICU staff could be followed over a set period of time. From those measures, further inference could possibly be made as to whether or not management of critical incident stress by debriefing helps to increase job satisfaction, increase retention rates, decrease feelings of burnout, increase team camaraderie, and decrease symptoms of PTSD. Quality of patient care could then be studied to see if these positive outcomes could lead to better overall care delivered to patients in the ICU. The future of this study would be large scale and as such would require much collaboration with mental health professionals who have the appropriate expertise to track the information mentioned like burnout and PTSD symptoms. The potential for this kind of guideline and the impact it could have on ICU staff for good could prove to be very beneficial and more study should be encouraged in this field. CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 27 References AACN. (2006). The Essentials of Doctoral Education for Advanced Nursing Practice. Washington, DC. Retrieved from https://utah.instructure.com/courses/377595/assignments/2966069#submit Battles E.D. (2007) An exploration of post-traumatic stress disorder in emergency nurses following Hurricane Katrina. Journal of Emergency Nursing 33 (4), 314-318. Blacklock, E. (2012). Interventions following a critical incident: developing a critical incident stress management team. Arch Psychiatr Nurs, 26(1), 2-8. doi:10.1016/j.apnu.2011.04.006
 Caine, R. M., & Ter-Bagdasarian, L. (2003). Early identification and management of critical incident stress. Crit Care Nurse, 23(1), 59-65. Dominguez-Gomez E. & Rutledge D.N. (2009) Prevalence of secondary traumatic stress among emergency nurses. Journal of Emergency Nursing 35 (3), 199-204
 Edberg, M. C. (2007). Essentials of health behavior: Social and behavioral theory in public health. Sudbury, MA: Jones and Bartlett. Everly, G. S., Jr., Flannery, R. B., Jr., & Eyler, V. A. (2002). Critical Incident Stress Management (CISM): a statistical review of the literature. Psychiatr Q, 73(3), 171-182. Gunusen, N. P., & Ustun, B. (2010). An RCT of coping and support groups to reduce burnout among nurses. Int Nurs Rev, 57(4), 485-492. doi:10.1111/j.1466-7657.2010.00808.x Kessler R.C., Berglund P., Demler O., Jin R., Merikangas K.R. & Walters E.E. (2005) Lifetime prevalence and age-of onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62 (6), 593-602. CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 28 Laposa J.M., Alden L.E. & Fullerton L.M. (2003) Work stress and posttraumatic stress disorder in ED nurses/personnel. Journal of Emergency Nursing 29 (1), 23-28, 87-92. Lavoie, S., Talbot, L. R., Mathieu, L., Dallaire, C., Dubois, M. F., & Courcy, F. (2016). An exploration of factors associated with post-traumatic stress in ER nurses. J Nurs Manag, 24(2), 174-183. doi:10.1111/jonm.12294 Maunder R.G., Lancee W.J., Balderson K.E. (2006) Long- term psychological and occupational effects of providing hospital healthcare during SARS outbreak. Emerging Infectious Diseases 12 (12), 1924-1932 Mealer, M. L., Shelton, A., Berg, B., Rothbaum, B., & Moss, M. (2007). Increased prevalence of post-traumatic stress disorder symptoms in critical care nurses. Am J Respir Crit Care Med, 175(7), 693-697. doi:10.1164/rccm.200606-735OC Mitchell, A. M., Sakraida, T. J., & Kameg, K. (2003). Critical incident stress debriefing: implications for best practice. Disaster Manag Response, 1(2), 46-51. Muller-Leonhardt, A., Mitchell, S. G., Vogt, J., & Schurmann, T. (2014). Critical Incident Stress Management (CISM) in complex systems: cultural adaptation and safety impacts in healthcare. Accid Anal Prev, 68, 172-180. doi:10.1016/j.aap.2013.12.018 Richter D. & Berger K. (2006) Post-traumatic stress disorder following patient assaults among staff members of mental health hospitals: a prospective longitudinal study. BMC Psychiatry 6, 15. Wuthnow, J., Elwell, S., Quillen, J. M., & Ciancaglione, N. (2016). Implementing an ED Critical Incident Stress Management Team. J Emerg Nurs. doi:10.1016/j.jen.2016.04.008 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 29 Running Head: CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU Appendix A DNP Project PowerPoint Presentation 30 Running Head: CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 31 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 32 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 33 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 34 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 35 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 36 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 37 Running Head: CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU Appendix B Institutional Review Board Exemption 38 Running Head: CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 39 Running Head: CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU Appendix C Stakeholder PowerPoint Presentation 40 Running Head: CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 41 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 42 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 43 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 44 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 45 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 46 Running Head: CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU Appendix D Guideline Details and ICU Staff Handout 47 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU • • • • • What is Critical Incident Stress? o "Emotional stress experienced by individual's secondary to their exposure to a specific incident or number of incidents" What could count as a Critical Incident in the RICU? o Medication errors o Unexpected patient deaths o Difficult family/patient interactions o Difficult staff member interactions o Massive bleeding, o Post mortem care o Work place violence Critical incident stress can accumulate and lead to serious problems: o Burnout o Compassion fatigue o Impaired clinical decision making o Low job satisfaction o High staff turnover o Symptoms of PTSD  30% of ICU nurses nationwide have symptoms of PTSD Critical Incident Stress Debriefing (CISD) aims to help alleviate and healthily manage stress o Two components  Emotional diffusing (done within 24 hours of events)  Formal debriefing (done 24-72 hours of events) o This guideline aims to start the emotional diffusing portion of CISD Guideline details: Most important to this session is we make it a safe environment where we all learn from the event o Event triggers a debriefing session o Staff involved gather for no more than 10-15 minutes sometime after the event, preferably before shift change o Discuss three things:  What happened?  What did we do well?  How can we improve for next time a similar event occurs? o Informal follow up the next day to assess:  Sleep?  Current thoughts?  Further assistance from manager or EAP? 48 49 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU Critical incident occurs: Debriefing guideline initiated Charge RN, NP, MD gather staff involved Emotional Diffusion occurs with 3 questions and discussion Work continues for remainder of shift, if someone needs immediate attention contact manager Follow Up 24 hours later If needed: further follow up with EAP/RN Manager CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU Appendix E ICU Staff Survey 50 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 51 Critical Incident Stress Debriefing Guideline Survey 1. Do you think a debriefing guideline would be beneficial in the RICU? 1. Not beneficial 2. Somewhat beneficial 3. Beneficial 4. Very beneficial Please explain: _________________________________________________________________________________ _________________________________________________________________________________ 2. How satisfied are you with the details of the proposed debriefing guideline? 1. Very dissatisfied 2. Somewhat dissatisfied 3. Neither dissatisfied or satisfied 4. Somewhat satisfied 5. Very satisfied Explain your answer: _________________________________________________________________________________ _________________________________________________________________________________ 3. How feasible do you think implementing the debriefing guideline in the RICU would be? 1. Not feasible 2. Somewhat feasible 3. Very feasible 4. Do you have any ideas to make the guideline more feasible? _________________________________________________________________________________ _________________________________________________________________________________ 5. Once the guideline is implemented, how usable do you feel it would be in the RICU? 1. Not usable 2. Somewhat usable 3. Very usable CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 52 6. What do you think the biggest barrier will be to using the guideline in RICU? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 7. What do you think will be the biggest facilitator to using the guideline? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 8. Comments/Concerns or other suggestions _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Please provide your: age_____ gender_____ and highest level of education________________ CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU Appendix F Final DNP Project Poster 53 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 54 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU Appendix G Snowbird CME Conference Abstract 55 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU 56 CRITICAL INCIDENT STRESS DEBRIEFING IN THE ICU; FEASIBILITY, USABILITY AND SATISFACTION Erick Howe, BSN, RN, DNP student Background: Critical incident stress is experienced by individuals that are exposed to an event or a number of events that happen suddenly, without warning, and disrupts the individual's feelings of faith and control in their environment. Staff that work in intensive care units (ICU) are often exposed to such events. Stress that results from these events can lead to mental health problems, including symptoms of post-traumatic stress disorder (PTSD). Nationwide, ICU nurses are reported to have a 30% incidence of PTSD symptoms. Critical incident stress debriefing (CISD) is a tactic that aims to help those that experience critical incident stress and begin to healthily manage stress. CISD is underutilized in hospital settings. Purpose/Objectives: This project aimed to create a debriefing guideline for ICU staff to utilize after a critical incident occurs in their unit. Objective one was to create the debriefing guideline. The second objective was to share the guideline with ICU stakeholders. Objective three was to revise the guideline according to stakeholder feedback. Objective four was to assess ICU staff perceptions of the feasibility, usability, and satisfaction with guideline content. The last objective was to disseminate the project details to a broader audience. Methods: Once a guideline was created, an educational PowerPoint presentation was delivered to ICU stakeholders. After obtaining stakeholder feedback the guideline underwent minor revisions. The guideline details were then relayed to 30 ICU staff members, along with a survey assessing their perceptions of the feasibility, usability, and satisfaction of the guideline. These results were compiled and reported back to the ICU stakeholders. Results: The survey response rate was 80% (24/30). Of the 24 responders, 58% (14/24) felt the guideline would be feasible for their unit; 79% (19/24) felt the guideline would be usable; and 71% reported they were "very satisfied" with the guideline content. Barriers that were identified included timing for the debriefing sessions, the lack of a designated facilitator to lead debriefing sessions, and consistency of use of the guideline. Facilitators to the guideline included the perceived benefit to new staff, the increased communication staff would experience, and the closed loop that the informal follow up would provide. Conclusions: According to ICU staff in this unit, a CISD guideline would be feasible and usable on their unit. Further study should occur to assess whether or not the debriefing guideline could be helpful in decreasing prevalence of PTSD symptoms among ICU staff.