Background Clinicians caring for the seriously ill frequently encounter challenging clinical scenarios including sudden patient decompensations, cardiopulmonary resuscitation, difficult family meetings, and deaths, which can negatively affect their mental health, job satisfaction, and well-being (1,2). Debriefing can be a useful strategy for discussing unanticipated outcomes, identifying areas for improvement, and supporting the emotional needs of the clinical team (3-5). It has been shown to reduce professional stress, as well as improve morale, concentration, clinical outcomes, and work engagement (6,7). At the same time, knowing what to say and how to facilitate a debriefing conversation can be difficult (8). Many clinicians may have never received training in how to lead a debrief effectively. This Fast Fact will discuss the PAUSE framework for effective debriefing of challenging clinical events (9). What is the PAUSE framework? This method focuses on skills and words to help team members debrief what went well and what could be improved after a challenging clinical event while also providing an opportunity for emotional processing and support. First designed and implemented in the Department of Medicine at Brigham and Women’s Hospital, PAUSE can be used for interprofessional team debriefings, as well as for 1-on-1 debriefing conversations between clinician peers or trainees and supervisors. The principal aim is to allow participants’ concerns to be heard and met with reassurance, empathy, and supportive advice after emotionally challenging scenarios. In the case of patient deaths, this debriefing framework can complement a moment of silence to honor the patient (see Fast Fact #432). Who can lead the PAUSE debrief? Any member of the team should feel empowered to lead a debrief conversation. In our experience residents, attendings, and interdisciplinary team members can all be effective leaders of the debrief in addition to those with more formal mental health training (for example social workers, psychiatrists, psychologists). The key to leading is having an approach or framework in mind. New leaders may benefit from co-leading or observing others before leading themselves. Setting The ideal setting is private, quiet, and removed from the patient and family. All clinical team members should be able to sit down if they wish. Before starting, invite introductions, allowing each participant to share their name and role in caring for the patient. PAUSE Framework: Prepare, Analyze, Understand, Sentiment, Educate Step 1: Prepare – Begin the debrief by setting the tone and establishing ground rules.

• Suggested language: “Our ground rules today are confidentiality, no judgment, and no blaming.”
• Rationale: Create an environment of psychological safety which minimizes fears of judgement, blame, or professional repercussions.

Step 2: Analyze – Either the debrief leader or any participant provides a brief clinical summary of what happened leading up to and during the event.

• Suggested language: “Can someone briefly summarize what happened that led to the event?”
• Rationale: This step aligns team members and fosters a shared understanding of the medical context before exploring emotional reactions. This is especially important for interprofessional team debriefing.

Step 3: Understand – Ask an open-ended question to invite participants to share their initial reactions.

• Suggested language: “How was this for everyone?”
• Rationale: The aims are to create an environment for participants to feel safe enough to share important emotional reactions and to provide data to the facilitator on how team members experienced the event.

Step 4: Sentiment – Explore which aspects of the clinical encounter went well and which felt challenging.

• Suggested language: “What parts of this went well? What parts felt emotionally challenging?”
• Rationale: Highlighting team successes can build camaraderie and reinforce effective practices; discussion of difficult aspects can normalize challenges and identify potential areas of improvement.

Step 5: Educate – Invite final reflections and one or two key lessons learned. Remind team members that debriefing is just an initial step and processing a challenging clinical experience can require time, courage, and hard work. Each team member’s support needs will differ, so remind participants of institutional resources for support. Doing so normalizes accessing professional support services and a dedication to wellness.  Clinicians should be encouraged, to take a few moments for quiet decompression and self-care before returning to clinical care.

• Suggested language: “What is one takeaway from this event?” and/or “I want to close with a reminder of institution’s emotional and mental health support resources…”
• Rationale: Asking for one or two takeaway points invites members to self-reflect and consolidate the discussion into key lessons learned which will be more likely to be applied in the future.

Summary A structured, easy-to-follow approach to debriefing challenging clinical events, such as the PAUSE framework, can provide peer-learning opportunities to share initial reactions, normalize emotional responses, highlight clinical successes, process challenges, and identify key lessons and areas for improvement. References

1. Busch IM, Moretti F, Campagna I, et al. Promoting the Psychological Well-Being of Healthcare Providers Facing the Burden of Adverse Events: A Systematic Review of Second Victim Support Resources. International Journal of Environmental Research and Public Health. 2021;18(10):5080. doi:10.3390/ijerph18105080
2. ‌Stehman C, Testo Z, Gershaw R, Kellogg A. Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I. Western Journal of Emergency Medicine. 2019;20(3):485-494. doi:10.5811/westjem.2019.4.40970
3. Welch-Horan TB, Mullan PC, Momin Z, et al. Team debriefing in the COVID-19 pandemic: a qualitative study of a hospital-wide clinical event debriefing program and a novel qualitative model to analyze debriefing content. Advances in Simulation. 2022;7(1). doi:10.1186/s41077-022-00226-z
4. Tannenbaum SI, Cerasoli CP. Do team and individual debriefs enhance performance? A meta-analysis. Human Factors. 2013;55(1):231-245. doi:10.1177/0018720812448394
5. Eng J, Schulman E, Jhanwar SM, Shah MK. Patient Death Debriefing Sessions to Support Residents’ Emotional Reactions to Patient Deaths. Journal of Graduate Medical Education. 2015;7(3):430-436. doi:10.4300/jgme-d-14-00544.1
6. Schmidt M, Haglund K. Debrief in Emergency Departments to Improve Compassion Fatigue and Promote Resiliency. J Trauma Nurs. 2017;24(5):317-322. doi:10.1097/JTN.0000000000000315
7. Mullan PC, Kessler DO, Cheng A. Educational opportunities with postevent debriefing. JAMA. 2014;312(22):2333-2334. doi:10.1001/jama.2014.15741
8. Topoll AB, Stowers KH, Arnold RM. Teaching Communication Skills in Real Time #438. Journal of Palliative Medicine. 2022;25(5):832-833. doi:10.1089/jpm.2022.0070
9. Vise, AS PAUSE manuscript- citation pending

Authors Affiliations: Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.
Conflicts of Interest: None.
Version History:  First electronically published in December 2023; originally edited by Sean Marks MD.