lable at ScienceDirect
Trends in Anaesthesia and Critical Care 40 (2021) 4e8Contents lists avaiTrends in Anaesthesia and Critical Care
journal homepage: www.elsevier .com/locate/ taccOpinionClinical debriefing: TALK© to learn and improve together in healthcare
environments
Cristina Diaz-Navarro a, b, c, *, Esther Leon-Castelao c, d, Andrew Hadfield a, c,
Sonia Pierce c, e, Demian Szyld f, g
a Department of Perioperative Care, Cardiff and Vale University Health Board, Cardiff, UK
b Health Education and Improvement Wales, Cardiff, UK
c TALK Foundation, Cardiff, UK
d Clinical Simulation Laboratory, Faculty of Medicine and Healthcare Sciences, University of Barcelona, Barcelona, Spain
e Department of Anaesthesia and Pain Medicine, Betsi Cadwaladr University Health Board, Rhyl, UK
f Department of Emergency Medicine, Brigham and Women's Hospital, Boston, USA
g Center for Medical Simulation, Boston, USAa r t i c l e i n f o
Article history:
Received 28 May 2021
Received in revised form
10 July 2021
Accepted 11 July 2021
Keywords:
Clinical debriefing
Reflexivity
Patient safety
Team communication
Quality improvement* Corresponding author. TALK Foundation, Cardiff, U
E-mail address: c.diaznavarro@talkdebrief.org (C.
https://doi.org/10.1016/j.tacc.2021.07.004
2210-8440/© 2021 The Author(s). Published by Elsevie
).a b s t r a c t
The use of clinical debriefing promotes team reflexivity, aligns with Safety II principles and allows
organisation leaders to engage clinicians in collaborative change. There is ample evidence of its benefits
regarding patient outcomes and team dynamics.
This article introduces TALK©, a practical approach to clinical debriefing which supports an inclusive
culture of dialogue and empowers clinicians to act and improve. It is underpinned by well defined values
that foster positive communication strategies and continued commitment to patient safety.
The TALK© structure consists of four steps: Target, Analysis, Learning and Key actions, which guide
individuals in having focussed and constructive conversations with practical outcomes. It enables
effective communication across diverse health care professional teams that work together on a regular or
occasional basis in any healthcare environment.
© 2021 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).1. Introduction
Clinical debriefing provides unique opportunities for team
communication, an essential element in organisations with a cul-
ture of patient safety. Its relevance is emphasized by the World
Health Organisation (WHO), defining debriefing as the process of
an individual or team formally reflecting on their performance after
a particular task, shift or critical event [1]. Debriefing allows
interprofessional teams to reflect on their experience, support each
other, share perspectives, identify learning opportunities and agree
on improvement needs.
Debriefing has long been an integral component of routine
safety practices in high risk and high stakes environments [2]. In-
ternational healthcare bodies recommend routine clinical debrief-
ing, advocating its use following invasive procedures (UK's National
Safety Standards for Invasive Procedures), post resuscitationK.
Diaz-Navarro).
r Ltd. This is an open access article(American Heart Association and European Resuscitation Council),
in theatre environments (WHO, UK's Five Steps for Safer Surgery)
and overall as a strategy to improve clinical performance (USA's
Agency for Healthcare Research and Quality) [3e8]. Furthermore,
recent findings suggest that interprofessional team debriefings
facilitate leadership interventions [9] and enhance peer support
and resilience during the challenges of pandemic surges and the
subsequent recovery periods [10,11].
Debriefing can take many shapes depending on its context,
environment and purpose. Notably, when debriefing is carried out
following an educational experience it should align with pre-
determined learning objectives according to the learners' re-
quirements and relevant curricula. Most commonly, debriefing
conversations for learning are held after a simulated experience or
a group learning activity [12]. However, other types of debriefing
aim to address different needs, such as identification of latent er-
rors, system improvement, psychological or post-traumatic support
[13e15]. Clinical debriefing typically focuses on interprofessional
teamwork, collective learning and patient safety [16].under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/
C. Diaz-Navarro, E. Leon-Castelao, A. Hadfield et al. Trends in Anaesthesia and Critical Care 40 (2021) 4e8There is extensive evidence of the benefits of debriefing in
clinical environments [17] and in particular regarding critical care,
resuscitation and operating theatres, where it has been linked to
improved learning, staff performance and patient outcomes [18,19],
as well as team dynamics and efficiency [20,21].
This article introduces TALK©, a practical approach to clinical
debriefing in line with the latest evidence, which aims to promote
an inclusive culture of constructive dialogue and empower clini-
cians to engage in continuous improvement action. It is under-
pinned by well defined values that steer teams towards positive
communication strategies, and continued commitment to patient
safety, which in turn support individuals and organisations to adapt
to variable and complex healthcare challenges.
1.1. The case for clinical debriefing
The relevance of clinical debriefing is advocated by evidence and
guidance spanning different spheres: psychology, education, pa-
tient safety and quality improvement. Accordingly, its use is aligned
with our current understanding of the role of reflexivity as a way of
drawing knowledge from experience through critical thinking [22],
hence being pivotal in continuous professional development and
adult learning. It supports Safety II principles, is beneficial for team
dynamics and allows organisation leaders to empower clinicians
and engage them in collaborative change.
Debriefing is a key resource in complex workplaces, as it aids to
improve team processes, enhance team effectiveness, bolster per-
formance and help organisations reflect and learn [14]. It also
supports shared reflective practice [8], which is essential for
healthcare professionals to continue their development throughout
their careers [23,24]; team reflexivity achieved through debriefing
does not only advance collaborative learning, but contributes to
staff wellbeing and resilience by decreasing burnout [25].
There is growing evidence of the positive impact of clinical
debriefing in patient outcomes [18,19]. As we broaden our focus
from safety I (which focusses on learning from risk and failure) to
safety II approaches (based on understanding the determinants of
success), we must acknowledge that performance variability and
adjustments are at the core of complex ever-changing healthcare
working environments, and that clinicians are best positioned to
identify excellent care as well as emerging improvement needs
[26]. It is also becoming widely accepted that we should make use
of everyday opportunities to learn from clinical experiences with
positive outcomes [27]. Participatory ergonomic methods and hu-
man centered design highlight the importance of genuine clinician
engagement in patient centered system design and improvement
[28]. Clinical debriefing fulfils this need, and TALK© guides clini-
cians to share reflective conversations exploring how to repeat
successful performances or improve, and empowers them to take
responsibility for acting upon those reflections.
Empowering clinical teams to make continuous small adaptive
changes results in slight improvements in performance at different
stages of clinical care, which build up to a cumulative benefit and
better patient outcomes, as illuminated by the theory of aggrega-
tion of marginal gains [29].
The Institute for Healthcare Improvement (IHI) psychology of
change framework advises healthcare leadership to enable and
encourage individuals and groups to act with purpose and courage.
This involves empowering clinicians to use their skills, knowledge,
experience, and capacity to act together in order to achieve patient
centered goals. Enabling teams to adapt and improve “generates
motivational rewarding experiences of autonomy, growth, and
community” and consequently increased commitment to quality
improvement [30].5Furthermore, as we move onto a third era for medicine and
healthcare, we require a moral milieu where the patient is at the
center, clinicians are valued and authentic dialogues are possible
[31].
In clinical environments, as in healthcare simulation, there are
more than one way to debrief [32]; implementing clinical
debriefing programs would benefit from a tailored approach to
local goals and context [16]. TALK© uniquely offers an easy, widely
applicable, values-based guide to clinical debriefing, designed for
clinicians by clinicians.
2. The TALK© framework
TALK© was created to promote patient safety and a supportive
culture of dialogue by guiding clinical teams to carry out short,
structured and solution based debriefings after everyday learning
events [33].
Embracing the latest clinical improvement theories, we
designed an innovative framework (Fig. 1) to prompt inclusive,
democratic and non-hierarchical clinical debriefing episodes,
which could be led by any team member with or without expert
debriefers. We designed a simple and easy to use tool that requires
minimal training in order to fulfil the challenge of adoption in busy
and high pressure healthcare environments.
The development process included design sessions and iterative
local reviews, involving multi-professional clinicians, academics,
quality improvement experts and psychologists from its inception.
Later, it included international peer review by a network of col-
laborators, expert discussions and feedback from initial users. A
consequence of both these partnerships and a new awareness of
cultural differences, was the development of a “safe container” [34]
for clinical debriefing, encapsulated by the TALK© values.
Further refinement of the concept, the production of freely
available educational materials and their translations to 8 lan-
guages have taken place under the auspices of a Marie Skłodowska-
Curie grant, awarded by the European Union's Horizon 2020
research and innovation programme. The consortium is led by
Cardiff and Vale University Health Board (Cardiff, UK) in collabo-
ration with the University of Barcelona, Hospital Clinic (Barcelona,
Spain) and Helse Stavanger University Hospital (Stavanger, Nor-
way). Additional information and materials are available on www.
talkdebrief.org.
2.1. TALK© values
Our underlying principles encourage teams to share reflections
meaningfully, in an inclusive, constructive and non-judgmental
way, looking to continually learn from experience and improve
patient care.
1. Positivity: we invite team members to highlight positive stra-
tegies and behaviours demonstrated by others, so that they can
be repeated by all. For example, “positioning the arm like this
works really well for this surgical procedure” or “when you
pointed out that the patient looked very pale, it mademe realise
that he might be bleeding”.
We also advise to avoid negative comments such as “you didn't
get me this piece of equipment”, and instead choose neutral
expressions during the conversation, for instance “this piece of
equipment was not available when needed, how can we orga-
nize ourselves differently and ensure that this doesn't happen
again?”.
2. Focus on finding solutions, rather than pointing out blame. For
example, we would avoid sentences like “you forgot to check
Fig. 1. TALK© debriefing card.
C. Diaz-Navarro, E. Leon-Castelao, A. Hadfield et al. Trends in Anaesthesia and Critical Care 40 (2021) 4e8this medicine” and encourage “this medicine was not checked;
let's consider what contributed to this and what we could do to
prevent it next time”.
3. Professional communication is encouraged at all times,
respectful and valuing everybody's input and perspective
whatever their background. This generates an environment in
which all team members feel able to contribute and voice their
thoughts.
4. Step by step: We propose that teams should start by identifying
everyday successes that can be replicated and disseminated or
small issues that can be easily addressed by their own inter-
vention, such as changes in timing or task allocation. When
more complex matters are identified, the team should actively
engage with individuals in a position to effect change and
endeavour to be part of the solution. A designated teammember
should take responsibility for following up each initiative and
ensuring that the intended outcomes are met.2.2. TALK© structure
A TALK© debriefing involves a team getting together after a
clinical event, to have a structured learning conversation in a
positive and non-threatening manner. The aim is to review the
event emphasizing successful behaviours, and to identify areas
where the team can improve their performance. To move forward,
key actions are identified and team members take responsibility to
ensure these are carried out.
It consists of 4 steps to ensure that individuals are sharing a
concise, focussed and constructive learning dialogue relating to the
clinical situation experienced (Table 1). It includes carefully
considered examples of sentences that enable the team to share
their perspective on a clinical situation and consider how to
maintain and improve patient safety. This way, team members
learn from their clinical experiences and agree on responsibilities in
a positive environment which contributes to staff engagement with
continuous improvement and to their wellbeing.
Through the fourth step, reflection turns into action. Individual
agency and accountability creates purpose and engagement, which
impacts positively on staff morale and enhances resilience [10].
Moreover, translating conversations into practical outcomes adds
value to the time invested in shared reflection.2.3. Recommendations for use of the framework
TALK© enables effective communication across diverse health
care professional teams that work together on a regular or occa-
sional basis; we consider a team to be any group of individuals who6are working together with a common goal. TALK© can be used
across a range of clinical settings including acute, non-acute, pre-
hospital and community care areas. The conversation should
ideally be held in a private and quiet environment.
All teammembers involved in the experience should be present
whenever possible, including not only clinical but administrative,
operational and ancillary staff. Any team member can initiate a
TALK© debrief. Familiarity with the tool is achieved through a short
training session which prepares team members to lead the
debriefing in accordance with the TALK© values. However, if the
situation experienced is emotionally complex, the team should
consider arranging a separate debriefing session, with adequate
time allocation and supported by an experienced trained facilitator,
a psychologist or a critical incident stress debriefing expert.
A TALK© conversation should take no more than 10min and can
be carried out immediately after a clinical case, at the end of a
clinical session or in due course, depending on the circumstances
and urgency of the situation. It can be used in pre-agreed circum-
stances or spontaneously, for example when team members are
exposed to new clinical experiences, when a new protocol is being
introduced, following good outcomes in difficult clinical situations
or after near misses or untoward incidents.3. TALK© implementation
3.1. Using the TALK© approach to clinical debriefing in small teams
is easy
The authors recommend familiarisation with the TALK© values
and structure prior to commencing its use. This can be achieved
during a free “TALK© user” training session (approximately 1 h of
learning) guided by a local instructor following standardised
training materials provided by the TALK Foundation.
However, a successful wider implementation requires the
application of improvement methodology. Specific guidance has
been developed based on Kotter's “enhanced 8 steps” as its change
management model [35]. Its aim is to support anybody acting as a
change agent in the promotion of TALK© implementation. It can be
used by clinical leaders, managers and teams in their journey to
make a difference.3.2. International adoption
TALK© was designed following our drive to promote guided
reflection within teams as a way to improve and maintain patient
safety, increase efficiency and contribute to a supportive culture of
dialogue and learning in any clinical environment. The Marie
Skłodowska-Curie grant, awarded by the European Union's Horizon
Table 1
TALK steps.
Step Description Recommended questions
1: Target The first step is to choose the focus of the discussion, being as specific as possible. Team members share their
perspective and agree on what is important to discuss.
“What shall we discuss to improve
patient care?”
2: Analysis Team members review the agreed target and explore how to repeat successful outcomes or identify areas for
improvement. They are encouraged to consider what helped or hindered communication, decision making and/or
situational awareness. As part of this step, team members propose improvement actions.
“This went very well, how can we do
this again?”
“This was challenging, how can we
do things better?”
3: Learning
points
New insights gained during the clinical experience or the conversation are shared by the team members. “What can the team learn from this
experience?”
“What have we learned during the
conversation?”
4: Key
actions
Team members agree on solutions. They also take responsibility to carry them out and follow them up. “What are we going to do?”
“Who is going to do it?”
“How will we all know that it has
been done?”
C. Diaz-Navarro, E. Leon-Castelao, A. Hadfield et al. Trends in Anaesthesia and Critical Care 40 (2021) 4e82020 has supported further development and fostered strong col-
laborations within and outside the grant consortium.
Current collaborations include initiatives in 18 countries across
5 continents. The TALK© approach has been used successfully even
when translated to other languages, allowing teams to gain new
insights on situation awareness, decision making, communication
and teamwork and leadership and improve their performance [36].
Given the overwhelming organic growth of our network, it
became apparent that we needed to protect the non-for profit
philosophy of this project. Hence the TALK Foundation was estab-
lished in 2018. It aims to maximise the opportunity for healthcare
improvement, patient safety and staff wellbeing through the use of
TALK© in order to empower a culture of patient safety through the
education of clinical teams and to promote and encourage further
patient safety initiatives.4. Conclusion
There is a vital need for healthcare institutions to support
reflection and learning in the workplace, as healthcare institutions
and their staff must continuously adapt to uncertainty and change
[37]. Embedding clinical debriefing into routine practice would fill
this gap; however, despite growing evidence of its benefits, this is
rarely achieved [17].
Clinical debriefing is a relatively new field of practice and
research. Multiple tools have been developed in recent years [16].
Overall, a growing body of evidence supports the practice of
debriefing in the clinical setting [9e11,15,18e20]. Notably, TALK© is
the only values based framework and the only structure designed
to be used with or without expert facilitators, requiring minimum
training.
We believe that for continuous improvement to be at the fore-
front of healthcare practice, clinicians need to be enabled and
encouraged to be agents of change. Clinical debriefing is an ideal
vehicle to prompt this engagement. The addition of everyone's
drive and accountability for improvement and the subsequent
marginal gains can lead to a substantial transformation of the way
we work. We all have a role to play, and each one of us can make a
difference.
Nevertheless, many avenues for research remain open, such as
how to maintain the momentum after implementation of clinical
debriefing programmes, quantifying daily improvement achieved
through debriefing or indeed, the cultural impact of embedding
debriefing in healthcare organisations worldwide.7CRediT
Cristina Diaz-Navarro: conceptualization, methodology, fund-
ing acquisition, writing - original draft. Esther Leon-Castelao:
conceptualization, methodology, funding acquisition, writing -
original draft. Andrew Hadfield: conceptualization, methodology,
writing - review & editing. Sonia Pierce: conceptualization,
methodology, writing - review & editing. Demian Szyld: writing -
review & editing.
Declarations
Ethics approval and consent to participate: ethical approval was
not required in the preparation of this article
Availability of data and materials: not applicable
‘Declarations of interest: none'.Funding
This work was supported by the European Union's Horizon 2020
research and innovation programme under the Marie Skłodowska-
Curie grant agreement No 734753. However, this article reflects
only the author's view and that the Research Executive Agency of
the European Commission is not responsible for any use that may
be made of the information it contains.
Acknowledgements
The TALK Foundation (legacy to the TALK© Project) registered
with the UK Charity Commission under Registration Number
1177093.
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