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Review DebrIeF: a collaborative distributed leadership approach to "hot

debrief" after cardiac arrest in the emergency department - a quality
improvement project

Article  in  Leadership in Health Services · March 2022

DOI: 10.1108/LHS-06-2021-0050

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Review
Review DebrIeF: a collaborative DebrIeF
distributed leadership approach to
“hot debrief” after cardiac arrest
in the emergency department – a
quality improvement project Received 2 June 2021
Revised 13 September 2021
15 December 2021
Shobha James 5 February 2022
Accepted 14 February 2022
Department of Emergency Medicine, Doncaster and Bassetlaw Hospitals NHS
Foundation Trust, Doncaster, UK
Prakash Subedi
Emergency Department, Doncaster Royal Infirmary, Doncaster, UK and
QiMET International, Sheffield, UK
Buddhike Sri Harsha Indrasena
Institute for Quality Improvement, World Academy of Medical Leadership,
Sheffield, UK and Department of General Surgery, Provincial General Hospital,
Badulla, Sri Lanka, and
Jill Aylott
Institute for Quality Improvement, World Academy of Medical Leadership,
Sheffield, UK and QiMET International, Sheffield, UK

Abstract
Purpose – The purpose of this paper is to re-conceptualise the hot debrief process after cardiac arrest as a
collaborative and distributed process across the multi-disciplinary team. There are multiple benefits to hot
debriefs but there are also barriers to its implementation. Facilitating the hot debrief discussion usually falls
within the remit of the physician; however, the American Heart Association suggests “a facilitator, typically a
health-care professional, leads a discussion focused on identifying ways to improve performance”. Empowering
nurses through a distributed leadership approach supports the wider health-care team involvement and
facilitation of the hot debrief process, while reducing the cognitive burden of the lead physician.
Design/methodology/approach – A mixed-method approach was taken to evaluate the experiences of
staff in the Emergency Department (ED) to identify their experiences of hot debrief after cardiac arrest. There
had been some staff dissatisfaction with the process with reports of negative experiences of unresolved issues
after cardiac arrest. An audit identified zero hot debriefs occurring in 2019. A quality Improvement project
(Model for Healthcare Improvement) used four plan do study act cycles from March 2020 to September 2021,
using two questionnaires and semi-structured interviews to engage the team in the design and
implementation of a hot debrief tool, using a distributed leadership approach.
Findings – The first survey (n = 78) provided a consensus to develop a hot debrief in the ED (84% in the
ED; 85% in intensive care unit (ICU); and 92% from Acute Medicine). Three months after implementation of
the hot debrief tool, 5 out of 12 cardiac arrests had a hot debrief, an increase of 42% in hot debriefs from a
baseline of 0%. The hot debrief started to become embedded in the ED; however, six months on, there were
still inconsistencies with implementation and barriers remained. Findings from the second survey (n = 58) Leadership in Health Services
suggest that doctors may not be convinced of the benefits of the hot debrief process, particularly its benefits to © Emerald Publishing Limited
1751-1879
improve team performance and nurses appear more invested in hot debriefs when compared to doctors. DOI 10.1108/LHS-06-2021-0050
LHS Research limitations/implications – There are existing hot debrief tools; for example, STOP 5 and
Take STOCK; however, creating a specific tool with QI methods, tailored to the specific ED context, is likely to
produce higher levels of multi-disciplinary team engagement and result in distributed roles and
responsibilities. Change is accepted when people are involved in the decisions that affect them and when they
have the opportunity to influence that change. This approach is more likely to be achieved through
distributed leadership rather than from more traditional top-down hierarchical leadership approaches.
Originality/value – To the best of the authors’ knowledge, this study is the first of its kind to integrate
Royal College Quality Improvement requirements with a collaborative and distributed medical leadership
approach, to steer a change project in the implementation of a hot debrief in the ED. EDs need to create a
continuous quality improvement culture to support this integration of leadership and QI methods combined,
to drive and sustain successful change in distributed leadership to support the implementation of clinical
protocols across the multi-disciplinary team in the ED.
Keywords Quality improvement, Hospitals, Doctors, Systems development, Hot debrief,
Cardiac arrest, Distributed leadership, Collaborative leadership
Paper type Research paper

Introduction
There are increasingly complex patients presenting to Emergency Department (ED) with
multiple co-morbidities, in a challenging environment where demand for emergency care is
outstripping the capacity of the service. A continued risk of this scenario is that physician-
led only, evidence-based protocols will continue to have low levels of compliance unless
clinical practice evolves in more collaborative and distributed ways. An example of the
potential for distributed leadership is the guidance for cardiac arrest where the American
Heart Association and UK Resuscitation Council recommend a hot debriefing following all
cardiac arrests attended by a health professional; however, it is not mandated that this
health professional should be a doctor (Panchal et al., 2018; Resuscitation Council, 2015;
American Heart Association, 2020). Hospital A is one of two hospitals which are part of a
Teaching Hospital Foundation NHS Trust in the north of England serving a population of
approximately 420,000 with 20 consultants, 30 junior doctors and in excess of 30 nurses.
Both hospitals, Hospital A and B, have an ED where patients have experienced “in-hospital
cardiac arrests” (IHCA). The ED team will face challenges to provide effective support for
IHCA as well as to be on alert for patients who are arriving by ambulance. This quality
improvement project was undertaken at Hospital A which has the larger ED in the Trust. In
2018, an audit found that in spite of cardiac arrests occurring, no hot debriefs were carried
out after cardiac arrest. These findings are not unique to Hospital A as other hospitals have
struggled with the implementation of hot debriefs reporting a start from a 0% baseline
(Gilmartin et al., 2019, 2020) and low levels of compliance as low as 47% (Swebeg et al.,
2018).
Quality improvement projects have been used successfully to support the implementation
of a hot debrief in emergency departments, with reports that this has had a direct impact on
improving the care to patients (Gilmartin et al., 2019, 2020; Sugarman et al., 2021; Walker
et al., 2020). However, there is very little evidence to identify if the improvement outcomes
reported in these projects are sustained over time. A focus purely on the implementation of a
hot debrief tool as opposed to a combination of improvement methodology with medical
leadership may miss vital opportunities required for creating a more sustainable long-term
change in the ED. It was the absence of leadership that was central to the findings of the Mid
Staffordshire NHS Foundation Trust Inquiry, which was found to have substantial failings
between 2005 and 2009 (Francis, 2010, 2013; Martin et al., 2015). The inquiry prompted a
review of the then NHS Leadership Competency framework which was revised with a
renewed emphasis on shared and distributed leadership styles and patient-centred leadership Review
(Storey and Holti, 2013). DebrIeF
In spite of these renewed efforts to promote shared and distributed approaches to
leadership throughout the NHS, medicine remains stuck within traditional hierarchies,
where individualistic and heroic approaches to teaching leadership prevail (Bolden et al.,
2006; Fulop and Mark, 2013). Transitioning from a leader-centric to a collective-leadership
approach is an emergent field in medicine, where traditionally medical leadership works
within the development of leader-centred competencies (Medical leadership competency
frameworks) (Bolden and Gosling, 2006; Bolden et al., 2006) as opposed to driving collective
and distributed efforts amongst the wider health-care team. A systematic review of
physician leadership programmes found there remains a narrow focus on developing
individual “leader” outcomes for doctors, rather than a focus on programmes that achieve
system-level outcomes and improvements for patients (Frich et al., 2014).

Evidence for hot debriefing

Approximately 35,000 patients experience a cardiac arrest in United Kingdom (UK)
hospitals every year, of whom fewer than 20% survive to leave hospital (Couper et al., 2013;
Nolan et al., 2014). Debriefing is a learner-focused, non-threatening technique used to assist
individuals and teams to reflect and improve performance for subsequent cardiopulmonary
respiratory resuscitations (CPR) (Bhanji et al., 2010). “Hot debriefing” is challenging to do in
a highly intense and sometimes chaotic setting (Knonick et al., 2015); however, the value of
debriefing staff after their involvement in a critical incident is widely acknowledged (Couper
et al., 2014; Gwinnutt et al., 2015). For the team, lessons can be learnt, and actions taken for
improvement as well as facilitating team members to open up and share their views which
would help to lower the incidence of post-traumatic stress Nolan et al. (2014). Hot debrief is a
real-time-based activity, intended to be rapid to respond to issues which occurred in the
cardiac arrest. This is different to a cold debrief which is usually planned to occur weeks
after the cardiac arrest and will result in deeper organisational and individual learning.
Clinical advantages include developing “reflection on practice” of the whole scenario,
exploring what was done well and what went wrong and what could have been performed
in a better way. This can in turn help to build up better future performances for subsequent
patient cardiac arrests as well as to improve adherence to resuscitation guidelines in clinical
settings (Bhanji et al., 2010). The benefits of a hot debrief can reduce psychological harm and
improve team performance, leading to prospective improved patient outcomes (Khpal and
Madeline, 2016). A hot debrief can advance knowledge, practice and confidence of the team
members involved (Allen et al., 2018) and can lead to greater organisational, individual and
team performance by approximately 20%–25% (Tannenbaum et al., 2013). While there is
substantial evidence that quality improvement approaches can support the implementation
of hot debriefing after cardiac arrest, there is very little evidence that this change can be
sustained over time and to what extent leadership contributes to the sustainability of this
change.
When staff are communicating time-sensitive and emotionally sensitive information to
families and staff, the acute post-arrest debrief can address:
 psychomotor skill issues;
 cognitive issues;
 team issues;
 family emotional issues; and
 professional staff emotional issues (Knonick et al., 2015).
LHS This can help contribute to improving the quality of patient care as this helps staff to
manage emotions (Reynolds et al., 2018). The conscious patients and their relatives at times
feel the stress of all the chaos accompanying a resuscitation process which can lead to
unexpressed mental trauma. Debriefing can potentially address these issues at its root.
Supporting staff through feedback and reflection is an extremely powerful tool (Sweberg
et al., 2018), yet undertaking a “hot” debrief after a cardiac arrest is often rare in clinical
practice (Reynolds et al., 2018; Tannenbaum et al., 2013).
The guidance from the Resuscitation Council states that a hot debrief should happen
after every cardiac arrest and should be led by a health professional who may or may not
be the cardiac arrest team leader (Panchal et al., 2018; Resuscitation Council, 2015). The
team leader cannot always lead the debrief as they may have to communicate with the
family, other professions and the police; however, the opportunity to debrief should not
be missed at these times. With other professionals seeking to rush back to their
respective departments at the post-cardiac arrest stage, a competent staff member
(usually a skilled senior nurse in the Emergency Department, with comparable skills to a
doctor in the management of the cardiac arrest) (Gilligan et al., 2005) can step up to this
role. This in turn can provide support to the physician allowing for the management of
cognitive load at this intense time (Armstrong et al., 2020). In a variety of situations
debriefings are the only opportunity for learning (Seelandt et al., 2021) and this has been
evident particularly during the COVID 19 pandemic, where teams had to form and
function on the spot with very little time for formal training (Seelandt et al., 2021). When
the learning from clinical debriefing has a clear pathway for action, visible quality
improvement follows, which in turn encourages clinicians to continue to engage in
debriefings. However, for debriefing to become culture and practice in the department,
two issues need to be addressed:
(1) The facilitation role in debriefing needs to be developed.
(2) There is a need for “top-down” support for debriefs to institutionalise it as a
deliberate routine in the department (Seelandt et al., 2021).

Cardiac arrest and trauma calls are typical scenarios involving teamwork. Each cardiac
arrest is a stressful situation for the team and, in addition to this, many of the team members
may not know each other and are expected to work together at very short notice to save the
life of a patient. The debriefs aim to be multi-disciplinary, timely, and often address issues of
team cooperation, coordination, communication, clinical standards, and equipment
(Theophilos et al., 2009). Structured team briefing protocals improve the performance of
resuscitation teams in subsequent resuscitation events (Berg et al., 2020). In the UK, the two
most commonly used team briefing protocols are STOP 5 (Jack and Walker, 2018) and
Taking stock (Sugarman et al., 2021), with the latter being an adaptation of STOP 5. A
structured debrief process may include the process and quality of care; review of
quantitative data (CPR metrics); reflect on teamwork and leadership; and address emotional
responses (Berg et al., 2020). One of the limitations of the current two tools is that both tools
do not directly include family issues, which is a recommendation in hot debrief (Knonick
et al., 2015). A comparison of the existing hot debrief tools and the new Review DebrIeF tool
is appraised in Figure 1.

Leadership
Leadership has been defined as a “shared or distributed process that can stretch over many
actors, rather than seen as the property of a single individual who has authority or
 Review
DebrIeF

Figure 1.
Comparison of hot
debrief tools

charisma” (Spillane et al., 2004; Raelin, 2016). This practice has been termed collective
leadership (Bolden et al., 2006; Kings Fund, 2011) and distributed leadership (Gronn, 2002;
Spillane et al., 2004).
Leadership is understood to be much more than a definition of the “leader” and his or her
“followers”. More recent work on Leadership theory recognises the role of ‘context’ and how
the personal, political, social, structural, spatial and temporal aspects shape perceptions and
experiences of leadership (Bolden et al., 2006; Grint and Holt, 2011). Health care has
traditionally been recognised as having high power distance between health professions,
with individualistic contributions. It will require medical leaders to lead the way in the
breaking of new ground to create a culture of more shared and distributed leadership in the
practice and context of medicine.
Achieving successful change requires passion and enthusiasm for the change by the
leader/change agent, so that others will also value the change (Miller, 2001) “the good leader
builds high levels of commitment and resolve” (Miller, 2001). Working in a facilitative and
enabling way with the wider multi-disciplinary team is more likely to generate support for
the change, as staff are likely to resist when change is imposed by others (Braithwaite, 2018)
particularly if they are unprepared for the change (Nilsen et al., 2020).
Medical leadership has a sustained impact on influencing the quality of medical care and
in turn influencing the way changes are implemented in clinical practice (Boyes, 2019;
Mountford and Webb, 2009; Ham et al., 2003; Castro et al., 2008; Fitzgerald et al., 203).
Medical leadership and management have been identified as being critical to the success of a
hospital and the improved quality of care for patients (Boyes et al., 2018; Goodall, 2011;
Bloom et al., 2009, 2013). While there is an evidence base to support the correlation between
medical leadership and improved quality of care for patients, there is a gap in the literature
to explore the increasing need for leaders to work in partnership, often in settings where
there is no formal or appointed leader (Brookes, 2011, p. 177). This is often the case with the
temporary formation of flexible and dynamic teams who come together when a patient has a
cardiac arrest in the ED.
LHS Specific aims
The SMART aim of the project was to design and implement a bespoke hot debrief tool in
the ED, that suited the specific ED context and that would also improve the engagement and
satisfaction of the wider health-care team, including the engagement of the family. The
objectives were to:
 use distributed and collaborative leadership strategies to build staff engagement;
 encourage and support participation from the wider health-care team to develop
change ideas to support the distributed spread of roles and responsibilities when
undertaking a hot debrief after cardiac arrest; and
 evaluate the spread of distributed leadership across professional groups.

This project was registered with the Quality Improvement Department at the Hospital, as
this work was quality improvement and not research, and hence ethics approval was not
required.

Method
A small team was convened to support this project, including a senior ED doctor (SJ), ED
consultant mentor (PS), quality improvement academic (JA) and senior statistical support
(HI). Support was additionally provided by the library services who supported the critical
search for literature of evidence for hot debriefs. An initial mixed methods survey (Survey 1;
Appendix) was designed and distributed amongst key stakeholders across ED, Critical Care
and Acute Medicine (AM). The results of the survey informed the design and process of a
hot debrief tool that would engage multiple stakeholders in the department. Various
iterations of the hot debrief tool were developed and tested out amongst different
disciplinary groups in the department throughout the timeline of the project. Nurses were
updated in shop floor huddles; Senior House Officers (SHO) and Registrars were engaged
through practical leadership training and hot debrief simulation training. Consultants were
updated through the consultant meeting and the clinical governance forum. Work was
carried out across the ED with a small sample of semi-structured telephone interviews to
discuss the current management system for hot debriefs and to identify gaps in the current
process which were causing barriers for each discipline to engage in the hot debrief process.
AM and Critical Care were updated and involved. The Clinical Governance Lead for the ED
helped set up the hot debrief tool on the ED database and guided the development of an
information sheet and supported the distribution of posters in the department as reminders
of the new revised team hot debrief tool and process. The Model for Healthcare
Improvement provided a structured framework to support the review of data and progress
of implementation of hot debriefs over time, while also providing a stakeholder engagement
process to explore change ideas and system-level adjustments. Leadership strategies were
reviewed within a monthly supervisory meeting during the time of this project. Finally, a
second mixed methods survey (Survey 2, Appendix) (n = 58) was designed to evaluate
experiences of distributed roles and responsibilities and identify evidence of collaborative
processes in the facilitation of the hot debrief process. Quantitative data were analysed
using statistical analysis and thematic analysis were used for qualitative data to generate
core themes.

Results
plan do study act (PDSA) 1 – March–June 2020 – Consulting stakeholders and generating a
consensus for change
 PDSA 1 engaged the staff team with a mixed-methods questionnaire (Figure 1) to gather Review
feedback on the experience of “hot debrief” after cardiac arrest. The survey was distributed DebrIeF
as a hard copy questionnaire and a total of 78 clinical and health-care staff across ED [and
two other departments who participate in cardiac arrest calls, Intensive Care Unit (ICU) and
AM] responded with overwhelming support (to introduce a standardised hot debrief
proforma across the Emergency Medicine Department (84% in ED; 85% in ICU; and 92%
from AM). Respondents reported that debriefs could improve the service provided to
patients in the department:
debrief helps with future improvements” (N11) “Should have a debrief to see if mistake, learn from
the cases and improve ourselves” (D7) “debriefing would be beneficial and improve the service
provided (N9); “most debriefing after IHCA improves the practice in the hospital” (D4) “we don’t
have a routine debrief though it can be helpful to go through what we did, why we did it and what
could have gone better” (N14).
Staff felt that hot debriefs had the potential to make improvements to the department by
learning from what had occurred:
“.hot debriefs are educationally beneficial and confidence building” (D4); “I think this would be
really beneficial and help team working” (N4); “debrief is important to help understand the
situation and keep your mind on the right track” (N5)“it would help organise my thoughts
on the cause of the IHCA and the outcome more effectively for future episodes” (N7)“very good for
solidifying knowledge and information” (D3) “after the debrief I felt a lot happier and came to the
conclusion it helps improve skills” (D11); “would be a good learning tool and a way of
understanding what happened and how we could improve” (N16).
In spite of the support for hot debriefing and the benefits identified, there were mixed
experiences of hot debriefing in the department with some describing poor levels of
organisation:
“sometimes can be chaotic” (N12); “could be improved” (N18) “nothing currently happens
regarding the briefing and would be very beneficial” (N4) “Definitely needs to happen” (D15)

“we can do better” (D3) “not a well organised debriefing at present. Needs training of the involved
individuals at every level in resuscitation team regarding debriefing session” (D1)
and others described a level of variation in the implementation of hot debrief in
practice:
“I have run debriefs but never attended someone else’s debrief” (D9); “depends on which doctor is
leading” (N12); “doesn’t always happen” (N13); “not done on a regular basis” (N20); “debriefing
should always happen, not just sometimes” (N21)
Respondents felt that the outcomes and impact of a good hot debrief could be measured by
reduced stress levels and increased staff morale and well-being:
“the stress levels depends on the quality of the person who leads the arrest” (N16); “Good way of
team relieving stress . . .. and encouragement to do better next time” (D13); “creates/maintains
group cohesion and increases staff morale” (D3); “as a team we tend to debrief ourselves and
support each other” (N10).
There was support for multi-disciplinary team leadership but recognising that specific
leadership skills needs to be developed for this role:
“varies a lot depending on which consultant is in charge. Nursing staff is ok but often lack
leadership” (N12).
LHS The data from Survey 1, combined with the audit data, were used to engage all
clinicians (prospective team leaders for the cardiac arrest team and nurses) in the study
and used to draft the first version of a hot debrief tool. At the end of the consultation
session, there were several questions and answers about the structure and process of
the hot debrief tool and the second iteration of the hot debrief tool was developed in
response to the feedback. There were significant concerns about how the hot debrief
would work in practice and it was agreed to run a hot debrief simulation training
session, which was originally designed to be a simulated training event in the
Emergency Department, but with Covid-19, this was designed to be delivered as a
simulation training event online. Understanding “Leadership” as leadership work
results in leadership becoming a consequence of collaborative meaning-making in
practice, that is a collaborative and distributed activity and not an individual one
(Raelin, 2016). It is argued that in time, people working together develop a sense of
mastery that they can work effectively, and this helps to develop a collective efficacy
(Bandura, 2000; Goddard, 2001; Raelin, 2016). The culture of weekly training for
emergency medicine doctors provided a mechanism to build the “sense of mastery” with
doctors, and further work was done to support the nurses to participate in a “collective
sensemaking” through morning huddles, which would help them to integrate new ways
of working with the hot debrief and to create a new and emerging culture (Bate, 2000).
The hot debrief tool was put on the database in the ED and the Clinical Lead for
clinical governance wrote to all staff in the department requesting their support for the
implementation of the hot debrief after cardiac arrest. There was positive support from
all staff in the department and for the month of July, from 1st to 20 July, there were three
cardiac arrests in the department and all three resulted in a hot debrief. While this
number represented a 100% use of the hot debrief tool, the sample was too small to
draw any conclusions. However, there did start to feel that a change in culture was
occurring in the department, as nurses became more engaged in the process and one of
the hot debriefs resulted in a cold debrief booked for the same month. The power of
learning from a debrief after cardiac arrest had started to filter through the department.
Prior to this point, there had been no previous cold debriefs carried out in the ED, led by
an Emergency Physician. The next stage would be to support distributed roles and
responsibilities for hot debrief and to create a more robust multi-professional process in
the department.
PDSA 2 – July–August 2020 – Changing behaviour and mindsets
By the second PDSA, it was found that there had been a significant drop in hot debriefs
in this period, and out of six cardiac arrests, only one hot debrief was carried out. Further
work was undertaken to contact each team leader to find out what barriers they had faced
that prevented their use of the hot debrief tool after cardiac arrest. By making contact with
individual team leaders, through semi-structured telephone interviews, it was found that
there were levels of apprehension and fear amongst some Registrars to take on the hot
debrief facilitation role. In contrast, nurses were reporting to SJ when hot debriefs were not
carried out and were providing ideas on how to support their implementation. It was after
the simulation training with Registrars and consultants, and with bespoke huddles with
nurses and health care assistants (HCAs), that questions started to arise from doctors,
nurses and health-care assistants such as:

Q1. Who will be the scribe and take responsibility to find and source the hot debrief
form?
 Q2. Should the hot debrief form be printed off from the database in ED or kept in a hard Review
copy folder? DebrIeF
Q3. How will we analyse the data to know if the hot debrief form contributes to
improvements in patient care in the department?
Work was undertaken with the nursing team and the health care assistants to encourage the
nursing staff to support the HCAs to develop their role by printing off the form to hand to
the team leader, although the nursing staff initially felt that this was their role and not that
of the HCA. Nursing staff were encouraged to meet in morning huddles to discuss any
barriers that could prevent the hot debrief occurring after cardiac arrest. A poster was
designed to help promote the hot debrief after cardiac arrest and to raise awareness.
PDSA 3 – August 2020 – Creating system change
All team leaders who facilitated a cardiac arrest throughout the second PDSA cycle were
approached through a personal email to ask if they would provide feedback on the hot
debrief process via a semi-structured telephone interview. Data from the telephone
interviews revealed that there was a level of apprehension from team leaders of seeking
feedback on the shop floor, and when consulting other team members, there were two
additional concerns:
 The team were sometimes confused as to who the team leader was when another
senior clinician was involved in the cardiac arrest.
 There had been new starters on rotation from the Deanery, which created
uncertainty, as the new starters had not been briefed about the hot debriefing
process after cardiac arrest.

Team leaders were asked for their ideas on what could be done to increase the number of hot
debriefs carried out and one suggestion was the use of arm bands which could help identify
the team leader. After working closely with the nursing team, the Clinical Nurse specialist
suggested other ways to embed the hot debrief as a by-product of other activities in the
department, for example through staff induction training.
A third suggestion from the nursing team was to make the hot debrief tool easily
available for new starters as a hard copy when they have not yet become familiar with the
online ED database. Having a drawer in the department labelled “hot debrief” was an easy
practical suggestion.
Distributed leadership with the hot debrief tool was discussed in the department with
doctors and nurses and it opened up a conversation to clarify who could be the facilitator for
the hot debrief. There was no written guidance that the facilitator of the hot debrief needed
to be a physician, yet it was a role that required consensus and trust if other clinicians were
to become involved in facilitating the hot debrief. It was discussed that the Advanced Nurse
Practitioner could be a facilitator for the hot debrief if they felt competent and confident to
take on this role. Arm bands were used to identify the team leader in the cardiac arrest team,
while discussion took place as to how to identify the hot debrief facilitator. The number of
hot debriefs for the third PDSA cycle increased to 42%.
PDSA 4 – September 2020–September 2021 – Improving the experience of cardiac arrest
for patients, families and staff
By the fourth PDSA and six months after the project started, work was undertaken with
the Nurse Practitioner Lead for resuscitation, and together the nursing and physician team
collaborated to make the hot debrief after cardiac arrest part of the guidance for the scribe.
This form was revised and has gone through a revised governance structure in the ED. Our
collaboration had now moved on to develop a resuscitation team consisting of members of
LHS the stakeholder group who came forward to be part of this work going forward. Other
departments in the hospital were in touch and wanted to share our learning and resources,
particularly members of the paediatric team. However, sustaining change in the ED over
time continues to be a challenge. There continues to be barriers with individual team leaders
who have been reluctant to lead the hot debrief and this was captured in the variation of
data presented in a run chart in Figure 2. A run chart is a method used in quality
improvement projects to plot data over time to identify if a change has resulted in
an improvement. The chart in Figure 3 shows that statistically a change has not resulted
in an improvement; however, nurse practitioners and health care assistants had invested
their time and support to develop the structures to embed hot briefing in the department, for
example, the Advanced Nurse Practitioner integrating the hot debrief into the mandatory
training for new staff and the HCA who identified a storage drawer for hard copies of the hot
debrief proforma.
To identify the extent of support for the hot debrief in the department and to evaluate
staff experiences of the hot debrief, a second staff survey was designed and distributed
across the ED (Survey 2). This time it was an online survey and 54 (n = 54) staff responded.
The results of this survey revealed that there was still variation in carrying out the hot
debrief with 25% of respondents never having participated (Figure 3).
Not all doctors believed that a hot debrief improves team performance (p = 0.94). When
asked if the hot debrief was beneficial overall, it was statistically significant that doctors
were likely to respond negatively (z = 2.55) while nurses responded positively (z = 2.21), p =
0.019 (Figure 4).
When doctors, nurses and health care assistants were asked the question: “please give
your opinion of the hot debrief being led by another competent team member (e.g. nurse) and
not team leader”, 15 (26%) provided favourable comments with support for another team
member taking on the role of facilitator of the hot debrief; examples include:
The debrief does not need to be the team leader - but it should be led by someone who is from ED,
who has been present for the whole duration of the cardiac arrest and is ALS trained. They should
also have significant experience of cardiac arrests. The team leader should be checking as the
arrest goes on that the staff that have been involved are handling their roles and that students
(both nursing and medical) should be asked if they are ok (5).

This allows for a more reflective approach as the team leader is focused on the patient more than
the human factors which could have an impact on patient outcome. Another member of the team
giving debrief could give a more holistic overview of the event (7).

Figure 2.
Run-chart for hot
debrief after cardiac
arrest in the ED
 Review
DebrIeF

Figure 3.
A total of 25% of
staff have not been
involved in a hot
debrief

Figure 4.
Nurses respond more
positively than
doctors to the hot
debrief

I would be happy for the debrief to be led by another competent team member. some individuals
respond in a more positive way to someone they can relate to (11).
There were five (9%) who commented that the role should be carried out by the physician/
team leader of the cardiac arrest:
LHS It is a good idea. But it is preferably led by a team leader. Whoever leads shouldn’t do it to bring
others down (13).

Would be more beneficial if led by the person leading the resus as they have oversight over the
whole incident (17).
It appears that nurses are supportive of distributed leadership and are happy to develop in
this role as they recognise the benefits of hot debriefing.
The odds of responding negatively (disagree or strongly disagree) vs responding
positively (agree or strongly agree) by the nurses was only 0.47 (p = 0.006) times that of
doctors by ordinal logistic regression (p-value for the Pearson test of the model fit was
0.061). However, job category had only a weak predictive ability (Somer’s D 0.16),
indicating that factors other than job category are involved in decision-making. Model
fitting with previous participation did not result in adequate model fit. Overall, it can be
concluded that hot debrief is viewed more positively by nurses than doctors and that
there has been marginal sustained improvement in the implementation of the hot
debrief, with more staff becoming experienced in the department since its
implementation (Figure 5).

Discussion
This quality improvement project set out to develop a multi-disciplinary approach to the
implementation and facilitation of a hot debrief after cardiac arrest in a UK NHS emergency
department, through distributed leadership mechanisms. Traditionally the team leader for
the cardiac arrest would take on the role of facilitating the hot debrief, regardless of their
level of confidence, competence or belief in this role. There are limitations to top-down
models of leadership when leadership is focused on the individual (Thorpe et al., 2011);
however, moving to an alternative approach requires reconceptualising leadership as
“practice” (Raelin, 2016), where leadership emerges and unfolds through the practice; for

Figure 5.
Marginal
improvement of hot
debriefs occurring in
the ED
example, the implementation of a clinical guideline to support the facilitation of the hot Review
debrief. Raelin (2016) argues that understanding leadership this way enables us to see DebrIeF
leadership as part of the task rather than to embed it within an individual. This would
support the wider inclusion and development of facilitators for the hot debrief process,
without stipulating that a physician must always take on this role. With the increased
shortage of doctors in ED, there is a timely opportunity to examine aspects of clinical
practice in ED that might benefit from embedding leadership in the task, with an aim to
transition to a more distributed leadership approach. One of the limitations of quality
improvement methods is that leadership practice is not defined or embedded within the
Model for Healthcare Improvement methodology (Langley et al., 2009), yet it is a critical
factor to secure engagement in the process of system improvement and to secure buy-in
from the whole health-care team. It requires a particular type of participatory and affiliative
medical leadership approach to support the continuous engagement of a wide range of team
members, but for this project, time spent in this stage was worthwhile to support
sustainability of the change process.
While staff engagement has been high throughout the duration of this quality
improvement project, it will take even longer to engage all staff to move from a physician-
only led process of “hot debrief” to a multi-disciplinary distributed leadership approach with
Advanced Nurse Practitioners. Currently, in spite of high levels of support for the
implementation of the facilitation of the hot debriefing tool by nurses, it has been
significantly challenging to embed the revised process and hot debrief tool in the
department amongst all physicians. Several change ideas were introduced within four
PDSA cycles using the Model for Improvement as a quality improvement method. However,
this project’s findings echo similar change projects in health care where change is incredibly
challenging to implement in practice. What has been of interest and of significance in this
project is how the use of medical leadership strategies engaged doctors (from many
specialities), nurses and health-care assistants through different interventions (e.g.
simulation, huddles, induction training, changes in clinical governance reporting and
additions of the hot debrief tool to the symphony database) to encourage a shared and
distributed leadership process. This quality improvement project supports the evidence that
a wide range of leadership styles and approaches are required for varying situations to
achieve specific outcomes (Chapman et al., 2014). Daniel Goleman suggests that the more
effective leader is able to interchange between leadership styles according to the context. For
this study, four out of the six leadership styles were used in the following ways.

Authoritative
Understanding the evidence base underpinning hot debriefs after cardiac arrest provided
authoritative medical leadership for this project in the department. This resulted in the
positive influence and subsequent engagement of many staff providing informal and formal
feedback to the first author on the hot debrief process throughout the duration of this
project.

Affiliative
Using the affiliative style of leadership interchangeably with authoritative leadership
promoted good relationships and communication across the multi-disciplinary group and
allowed for sensitivity to inquire about the welfare of team members who did not feel
confident in their role as a facilitator in the hot debrief process.
LHS Coaching
This was used with medical colleagues and nurses to build further capacity and capability
in leading and facilitating the hot debrief; doctors and nurses were supported with coaching
to develop their skills and experience through simulation training and ED shop floor
huddles. It was important to support the efforts of others on the team and support their
development of skills to widen the team available to take on the role of facilitating the hot
debrief process.

Democratic
The democratic leadership approach defined this project from the beginning. This approach
encourages participation and the exchange of ideas – especially when faced with a complex
problem. Both staff surveys were based on these principles.
However, two of the six styles recommended by Goleman (Goleman, 1995) Ref:
Emotional intelligence: Why it can matter more than IQ ) that were not used during the
time of this project, were ‘commanding’ and ‘pace-setting’ approaches. The
commanding approach provides clear direction and expects others to follow,
challenging others when they are not performing. When physicians were not
comfortable with taking on the role of facilitating the hot debrief, it was not appropriate
to use a commanding approach as this was likely to have a negative effect. In a similar
way, pace setting requires the leader to set the pace to achieve high performance. The
run-chart in Figure 2 shows the variation of implementation of the hot debrief in the ED
after cardiac arrest. It is important to continue to collect data and to measure
performance but this should not be used to compel behaviour. Instead, team working
requires the development of trust, openness and honest communication. The focus for
sustaining the hot debrief in the department over time is to build the number of staff
who can take on the different roles to deliver the “hot debrief” in the ED, with the skills
that provide individuals to participate in ways matching their own levels of competence
and confidence. This will require different leadership styles to be used appropriately
according to the situation and context and for medical leaders to use a wide range of
strategies that support motivation and engagement to achieve trust, which will in turn
will deliver the outcomes of distributed leadership.

Conclusion
This quality improvement project identified overwhelming support for the full and
consistent implementation of a hot debrief after cardiac arrest. This supports the
evidence from the literature of the benefits for learning, future quality improvements
and team working amongst staff, patients and families of this process. Throughout the
duration of this project, it was difficult to achieve the level of change that was required
to satisfy all team members as physicians who held power and position as team leaders
were less likely to believe in the hot debrief when compared to nurses. Medical
leadership strategies were used with physicians and other team members to identify
barriers and explore ways to improve the process using PDSA cycles, with varying
effect. Nurses and HCAs embraced the collaborative nature of this project and were
keen to work in distributed ways to collaborate in the implementation of the hot debrief.
This project succeeded in gaining a collaborative consensus (medical and nursing) in its
approach to the induction of staff and the briefing of doctors on rotation about the
implementation of the Review DebrIeF tool. While collaborative leadership has been
evidenced throughout this project since the start, distributed leadership has been much
more difficult to achieve. It is hoped that as more physician leaders explore the merits
and the potential for improved quality outcomes of distributed leadership through Review
specific quality improvement projects, then this will provide more opportunities to DebrIeF
review policies that provide physician-only leadership in non-clinical activities.

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Appendix Review
Surveys 1 and 2 to evaluate staff experiences of hot debrief after cardiac arrest in the ED DebrIeF

Corresponding author
Jill Aylott can be contacted at: jill.aylott@waml.co

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