Introduction

Being a healthcare professional in both paediatric and adult hospitals means potentially encountering tragedies and stressful events involving conflict, misunderstanding, and moral distress (Breen et al. 2014; Everly and Mitchell 2000; Kelly 2020; Boss, Geller, and Donohue 2015), despite the efforts of highly skilled and experienced health professional teams (McDougall, Delany, and Gillam (2016). The following hypothetical but realistic case scenario, based on our own professional experiences, provides a picture of the sort of tragic and stressful event that can occur.

Charlotte was a two-year-old toddler, the only child of her two parents, Amanda and David. She was born with biliary atresia—a serious congenital condition involving blockage of the ducts that carry bile from the liver to the gallbladder. At twelve months, Charlotte had surgery to remove the blocked ducts and replace them with a segment of her small intestine (Kasai procedure). However she experienced recurrent episodes of cholangitis (infection in the biliary tree) post the Kasai procedure. After only four months at home with her parents, she was back in hospital and required a living donor liver transplant, for which her father volunteered to be the donor. Charlotte developed a life-threatening infection one month after the transplant which required her to be readmitted to the Paediatric Intensive Care Unit (PICU) with gram negative septic shock, respiratory failure, and intractable coagulopathy. Her mother, Amanda, became increasingly distressed by her daughter’s continued need for invasive procedures. She eventually said to staff that “enough is enough.” However, Charlotte’s father, David, stated that he “cannot give up on his child.”

There was an urgent need to come to a decision about life-sustaining interventions and their cessation. Although the PICU healthcare team and their palliative care colleagues had a number of discussions with Charlotte’s parents on a day-to-day basis, Charlotte’s parents had been unable to reach agreement about clear and specific advanced care directives and any treatment limitations due to their contrasting views. Hence there was ongoing uncertainty for the healthcare team about how they should respond in the event of an acute deterioration.

Charlotte had a cardiac arrest after ten days in PICU. At the time, because of the uncertainty and lack of agreement about goals of care, the doctors felt they had no choice other than to begin CPR. They spent fifteen minutes providing chest compressions all the time thinking that this was futile and not in Charlotte’s interests. This did not save Charlotte’s frail life. Several team members were extremely distressed in witnessing what they regarded as an unnecessary resuscitation on such a sick child, and some believed that Charlotte and her parents were denied the opportunity for a “good death.”

The situation of two-year-old Charlotte was medically complex. It was also tragic for her family. For her parents, despite many discussions with doctors about the risks and benefits of the Kasai procedure and the liver transplant, and a supportive multidisciplinary team involved in providing psychosocial and mental health support for their difficult journey, Charlotte’s short life involved grief, misunderstandings, and uncertainty. For the many health professionals caring for her in her final months of life, it was challenging and distressing. Our focus in this paper is on the stressful event experienced by the health professionals. Our use of the term “stressful event” is similar to the notion of a critical incident and refers to an event typically outside the usual range of experiences which challenges or overwhelms a clinician’s ability to cope (Everly and Mitchell 2000; Lützén and Ewalds-Kvist 2013). When not adequately addressed, the effects of these events may accumulate for clinicians and can manifest as fatigue, demotivation, job dissatisfaction, feelings of isolation, burnout (Mihailescu and Neiterman 2019) PTSD, (Alden, Regambal, and Laposa 2008; Panagioti et al. 2018), and depression (Jennings and Slavin 2015; Rushton et al. 2021). Ultimately if clinicians are stressed and inadequately supported, their capacity to provide timely, competent, and compassionate healthcare diminishes (Liselotte N Dyrbye and Shanafelt 2011).

Many different approaches to supporting healthcare professionals after stressful events have developed over time. They include suggestions for self-care such as “mindfulness,” relaxation and exercise, cognitive behavioural therapy (Atallah et al. 2016), strategies to build emotional and moral resilience (Chaukos et al. 2018), and interventions to improve workplace systems such as demanding rosters, administrative burdens, and organizational culture (Dyrbye et al. 2017). Other approaches include facilitated reflective discussions aimed at supporting and educating health professionals to support their psychological safety and assist them to develop skills and self-awareness to sustainably manage workplace stressors and continue to develop as health professionals (Everly and Mitchell 2000; Heffron, Reynolds, and Talbot 2016; Udo, Melin-Johansson, and Danielson 2011; Edwards, McClement, and Read 2013). In recent systematic reviews of published approaches to address moral distress—a common component of stressful events (Morley et al. 2021; Imbulana, Davis, and Prentice 2021; Prentice et al. 2016)—educational programmes which included communication techniques, role play, formulation of action plans, and structured reflection were found to be the most prevalent and effective (Morley et al. 2021).

In this paper, we focus on four types of facilitated structured reflective approaches which aim to assist health staff to be psychologically safe and to develop skills to reflect on and process stressful events, including those involving experiences of moral distress. A common goal of each of the four approaches is to enable health professionals to make sense of stressful workplace experiences and ultimately to grow professionally. We draw from our collective experiences in a large children’s hospital and from the literature more generally to delineate the practical processes followed (table 1) and the goals, underpinning theoretical concepts, and facilitation methods used (table 2) in four established reflective discussion approaches. We then discuss how each model might respond to a case such as Charlotte’s to broadly illustrate the types of processes followed and possible outcomes of these reflective discussions. Reflective discussions do not necessarily involve a review of clinical decision-making but rather focus on the different responses, needs, and experiences of the health professionals involved. So our hypothetical scenario of Charlotte is framed to portray an emotionally charged and distressing situation involving a gravely ill child, complicated by disagreement between her parents and conflict and uncertainty amongst health professionals, and does not provide clinical details.

Table 1 Four reflective discussion models
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Table 2 Underpinning theory and goals
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Each of the four approaches we review has the potential to open up feelings of uncertainty, frustration, sorrow, anguish, and moral distress for participants. We argue, therefore, that it is crucial a facilitator has the specific skills and training (Edwards, McClement, and Read 2013) required to safely lead the discussion and is clear about the nature, scope, safe application, and limits of each approach.

Psychological First Aid

Psychological first aid (PFA), also known as mental health first aid, specifically focuses on providing support to a person to ensure they are psychologically safe after witnessing or being involved in a traumatic or stressful situation (primary exposure). It may also be applied to those who have experienced secondary (family, colleagues) or tertiary (other patients and community) exposure. Originally developed to assist people following significantly traumatic events such as terrorism and natural disasters (World Health Organization 2011), it has increasingly been used in work environments following a critical or stressful event in the workplace (Cotton 2014), in particular, in the authors’ own hospital environment.

In health settings, the focus of PFA is to assist a clinician to consider what he or she needs to feel safe and supported. This is often achieved by validating a person’s emotional responses through reassurance and practical and immediate support. PFA intentionally does not review the clinical details of a traumatic event and discourages early analysis of what occurred (Rose et al. 2002). This recognizes that the facts may not be immediately clear after an event and that the clinician may not be emotionally ready or psychologically equipped to safely discuss the event (Couper and Perkins 2013; Vaithilingam, Jain, and Davies 2008).

Personnel facilitating PFA do not require expertise in counselling or debriefing but should have training in the scope and limits of PFA. The expertise necessary to facilitate a psychological first aid includes active listening and an ability to assist a person to share their particular concerns and express what they need to feel safe. Not all clinicians will require or desire PFA, but it is important for clinicians to know that this form of support is available and readily accessible (Kessler, Cheng, and Mullan 2015).

In Charlotte’s case:

PFA would likely occur immediately after, or potentially in the days following, her death, as PFA can be safely delivered at any time after a challenging event. A clinician trained in facilitation of PFA (medical, nursing, or allied health) would approach any identified vulnerable clinical and non-clinical staff who had been involved in or who had observed Charlotte’s resuscitation and offer an optional individual “time-out” to support their psychosocial well-being. Using the “Look, Listen, Link” framework for PFA (World Health Organization 2011) (figure 1), a safe environment in which to engage in conversation, would first be identified. The facilitator would then listen to the clinician’s feelings and concerns about Charlotte’s deterioration and death whilst intentionally avoiding going into significant details about what happened. Support for a person’s psychological safety may require a period of leave from work and/or linking the clinician to internal (hospital) and external support services. Ideally, clinicians who have participated in PFA would receive follow-ups by colleagues over a period of time to check their psychosocial well-being, and additional support and ongoing referral to professional services would be provided when and if necessary.

Fig 1
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Look, listen, link framework. Adapted from World Health Organization (2011)

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Critical Incident Stress Debriefing (CISD)

Critical incident stress debriefing, as defined by Mitchell (Mitchell 1983) (figure 2) and Mitchell and Everly (Mitchell and Everly 1995), was initially developed as a group intervention for emergency first responder personnel and as part of a multistep process for critical incident stress management. It has a broader focus than PFA, encouraging clinicians to reflect on a range of factors which may have influenced an event, such as medical facts, management decisions, and professional roles. CISD also allows room for clinicians to think about their emotional responses to an event with the aim of facilitating psychological closure and enabling a team to return to or continue with their work.

Fig 2
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Adapted from Mitchell’s (1983) 7 stages of CISD

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The reflective process follows seven formalized stages originally outlined by Mitchell (1983). The incorporation of emotional and psychological response (stage 4) in a CISD is a key difference from other types of stress debriefing such as “hot,” “technical,” or “clinical,” debriefs. In these latter approaches, the focus is limited to a discussion of the technical aspects of a clinical event, including the flow of events, clinical decisions made, and outcomes for the patient (Couper and Perkins 2013; Kessler, Cheng, and Mullan 2015; Mullan, Kessler, and Cheng 2014). It is also different from psychological first aid as the emphasis is on review and analysis of technical and psychological thoughts, requiring an expert to facilitate this method of debriefing.

In CISD, in order to safely and effectively move attendees through reflection about clinical as well as emotional aspects of an incident, a CISD facilitator needs skills to lead a clinical and factual review with all members of the multidisciplinary team who were involved in a case, whilst at the same time cultivating a safe environment that allows each health professional to contribute their feelings and personal responses about an event. Important facilitation skills include a non-judgmental approach, a capacity to draw out specific facts and management responses that occurred, and to notice, acknowledge and validate personal reflections and emotional reactions experienced. In the final steps, participants are prompted to analyse implications for future practice including team interactions and ensure the participants are safe and able to return to clinical practice. Although CISD or a similar form of debrief is anecdotally commonly sought out by health professionals involved in the event, CISD should not be a compulsory process as research suggests it may increase post-traumatic stress disorder (Bledsoe 2003; Rose, Bisson, and Wessely 2002). It is ideally provided one to two weeks after the challenging event, to allow attending staff time to process the emotional aspects of the event and be able to discuss their feelings in a group setting.

In Charlotte’s case:

Ideally around one week after her death, a formal group CISD would be arranged. A trained facilitator or psychologist would lead the discussion. In addition, a clinical content expert would provide insights or answers to questions raised in regard to the clinical aspects of the event. Any member of the treating team involved in Charlotte’s care would be invited to attend, although participating is entirely voluntary. Following an introduction that sets out the ground rules of engagement and intent of the CISD (figure 2), an outline of the clinical facts of the case and timeline of events would be presented as background context for the review. Then attendees would be invited to share the nature of their involvement and any emotional reactions or thoughts associated with the event (Lane 1994). In Charlotte’s case, topics may include acknowledging clinicians’ feelings and concerns about the resuscitation, whether there were opportunities to address parental conflict or disagreements earlier, and the challenges of advanced care planning when family members disagree between themselves or with clinicians. According to the CISD approach, the discussion would also include the clinical facts and seek understanding about whether Charlotte’s outcome could have been anticipated or planned for as part of her clinical trajectory.

Discussion points arising during a CISD about Charlotte’s case may include the need for more clarity about legal and ethical positions related to Charlotte’s advance care directives and how staff might seek support from senior leadership leading up to resuscitation. A brief summary of the discussion and key outcomes would be provided to participants with reminders of avenues for further support and contact should further questions arise.

Clinical Ethics Review

A clinical ethics review begins from the premise that ethical knowledge and skills already permeate healthcare. Clinicians do not need an ethicist to provide epistemic access to norms that guide their practice (McCullough 2020; Verkerk and Lindemann 2012). However, common features of stressful events in healthcare are that they involve misunderstandings, conflicting or unarticulated goals of care, and differing perspectives about harms or burdens associated with clinical care. The goals of a clinical ethics review are to provide an opportunity for participants to discuss and unpack ethical concerns underlying their emotional responses. The process of unpacking often begins with identifying and reviewing decision points along the way to the outcome, identifying what options were open at each point, what ethical values were being promoted, balanced, or traded off, and what constraints were placed on decision-makers.

Some of these decision points may represent what Komesaroff (1995) describes as micro-ethical decisions. These include moments such as interactions aimed at establishing trust, probing a patient’s or parent’s fears and hopes, or introducing changes to treatment goals. These micro-points in communication and delivery of care do not have the obvious trade-off between ethical values that are characteristic of the more classic ethical dilemmas. However, they are still ethically important and may be experienced as incremental forms of moral loss or distress by clinicians.

An important goal in clinical ethics reviews is to enable clinicians to name and process these experiences by providing an opportunity and some appropriate, shared language. The idea is to move participants from feelings of moral distress or unresolved moral tension about a past event towards greater moral clarity about what could or should have been done in the circumstances (Guidry-Grimes et al. 2019; Newson 2015; Nussbaum 1994; Morley and Horsburgh 2021).

As part of this process, the facilitator may introduce ethics concepts and ways of identifying and weighing up different values and moral perspectives about decision points and experiences (McDougall, Shadbolt, and Gillam 2020; McMillan 2018). The central idea is to “bring moral reasoning to bear” on a clinical event or experience (Battin 2013). One important task of moral reasoning in relation to stressful events is to help participants distinguish between moral distress (emotion arising from a belief that they were involved in an event that was morally wrong due to some form of constraint) (Jameton 1984; Epstein and Harmric 2009; Prentice et al. 2016) and moral regret (emotion arising from recognition that in a trade-off between values, something of value is lost even when appropriate moral balancing informed the decision) (Gasdaglis 2019). Clinical ethics reviews are usually conducted by a clinician with clinical ethics expertise (obtained via formal bioethics or medical ethics study) or a clinical ethicist with a background in philosophy, bioethics, or medical ethics (Agich 1995).

An ethics review may be conducted as a one-on-one discussion, with a group of health professionals from the same discipline or as part of an interprofessional team discussion. The topics are determined by the participants, in a similar vein to the methodology of a semi-structured qualitative interview, where there is an overriding area of interest but the participant determines the specific focus (DiCicco-Bloom and Crabtree 2006). The five steps and accompanying questions listed in figure 3 show how a facilitator might begin with participants’ feelings and perspectives about a situation, then through a series of questions, assist them to identify ethical concerns or values underling these responses and articulate or specify the nature of the ethical concern (Gillam et al. 2014). From there, the facilitator encourages reflection on what decisions were made, what other decisions could have been made, and what the ethical considerations (possibly competing with each other) were. The facilitator encourages participants to reflect on their ethical thinking and understand how others could see things differently and how to manage situations where there are different ethical views.

Fig 3
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Questions to guide clinical ethics review

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A group discussion is particularly conducive to raising awareness of how colleagues are identifying, considering, and balancing values (McDougall, Shadbolt, and Gillam 2020). This has the effect of highlighting the presence of differing moral perspectives within the team (Burbules and Rice 1991), providing insight into why moral complexity may not easily be resolved, and acknowledging that ethical reviews are not an indication that someone is unethical or uncaring. A further effect of ethical reviews for health professional teams is to reinforce the notion that individual health professionals should not feel they must review and process morally complex experiences on their own (McDougall et al. 2014).

In Charlotte’s case:

Participants would first be encouraged to discuss what they had found to be upsetting, distressing, or morally challenging about the situation, with the aim of unpacking what ethical or moral concerns might be involved. Participants may report feeling distressed about the way Charlotte died. Asked to be more specific, and think about values, they may explain that the effort to resuscitate Charlotte was futile, harmful for Charlotte, traumatic for the clinicians involved, and/or unfair for Charlotte’s mother who did not want this type of ending. These ethical concerns would be acknowledged then further unpacked to get a sense of the ethical weight or significance of each. The facilitator may introduce ethical concepts to assist in this. For example, “futility” is a complex and contested concept (Gillon 1997); understanding its different meanings may help participants to clarify their thoughts. Resuscitation may have been futile in relation to the goal of keeping Charlotte alive but not futile in relation to a parent’s goal of doing everything possible to save their child.

The next step is for participants to work through what happened in the lead-up to the stressful event, seeking to identify decision-points (places where an ethically important decision was made) and think about whether different decisions could have been made at those points. This leads participants into a guided discussion of weighing up the ethical pros and cons of those possible decisions, taking into account uncertainty and subjectivity in this process. The facilitator would encourage participants to reflect on whether their understanding of the ethical situation had shifted or expanded—for example, moving from moral distress to moral regret.

The aim of a clinical ethics review is not to reach a decision about what should have been done or to blame individuals for doing something wrong. Rather, the aim is for participants to make moral sense for themselves out of what happened and their initial moral reactions (McMillan 2018). This will enable development of nuanced ethical understanding and build capacity to work collaboratively and effectively in a context where people sometimes have different values and come to different ethical views.

Clinical Supervision

Clinical supervision is a specific approach to supporting staff to learn from everyday practice. It is also called reflective supervision and needs to be distinguished from supervision as a form of monitoring, assessing, or credentialing staff (Bond and Holland 2011). The overarching goal of reflective clinical supervision is to provide a sanctioned context to learn to think about challenging work with patients, families, and colleagues, and through that reflection, to develop compassionate and safe clinical practice. Participants are encouraged to explore openly what may have been missed in close and detailed work with families, to learn about their own capacities, and to make sense of and give meaning to their own and others’ behaviours, emotions, beliefs, and intentions. This type of reflection is described as reflective functioning—a process where a person or a group of people are invited to step back from the immediate and intense experience of their work and to make sense of and then learn from such events (Fonagy, Gergely, and Jurist 2018; Heffron, Reynolds, and Talbot 2016).

Developing out of the disciplines of psychology, social work, and psychiatry, and informed by theories of psychoanalysis (Obholzer and Roberts 2003) and reflective functioning (Fonagy and Target 2005), clinical supervision works to acknowledge, affirm, and at times bear witness to clinicians’ experiences. Ideally, the facilitator should not have a day-to-day role in the team’s work and can therefore be interested but not invested in an outcome. Clinical supervisors may be originally trained in any of the medical or allied health disciplines, and most would have undertaken considerable supervision themselves. Through open and facilitated discussion, supervision aims to promote collegial support, team building (Heffron, Reynolds, and Talbot 2016), and mutual respect (Pawl 1995) and to increase resilience of individual clinicians (Fonagy, Gergely, and Jurist 2018; Terry et al. 2020). A clinical supervisor supports participants to focus, explore, and make sense of their experiences, thoughts, and feelings directly connected with their work. Figure 4 provides an example of the types of steps involved in clinical supervision.

Fig 4
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Structure and facilitation approaches for a clinical supervision session

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The process of clinical supervision offers and encourages participants to develop new or alternative skills for working with patients or colleagues. Often a staff member will put into words a dilemma a whole team has experienced, and a new understanding arises for the group. As Gilkerson (Gilkerson 2004) argues, clinicians already know a lot about what to do, and the challenge is to carry out the approaches given the complexity within the families for whom they care.

Menzies (1960) from her pioneering observational studies in NHS hospital wards, similarly noted the emergence of “social defence systems” within hospital systems, which had the effect of sometimes detaching staff from feelings (Bloom 2004). To address this inherent complexity which patients and families bring and the impact of institutional systems of care, Obholzer and Roberts (2003) highlight the advantage of supervisors being informed by psychoanalytic/systemic frameworks because they can increase participants’ understanding of how group effectiveness and morale can be undermined within institutions.

Questions brought to supervision may be existential in nature—for example, the experience of witnessing cumulative deaths or loss of compassion or gender/power problems in a unit. The experienced supervisor might respond by using a reflective mode to address the needs of the staff members at the time. The supervisor may also structure and guide the discussions by offering pertinent hypotheses to explore the issue.

At a group level, clinical supervision enables a team to develop their own “reflective functioning,” which, in turn, increases the group’s capacity for thinking together to navigate a path through complex and emotionally charged experiences (Heffron, Reynolds, and Talbot 2016). Building this type of reflective capacity, competence, confidence, and effective working (Costello 2020) is best fostered by organizational support for building a culture that values staff confidence in the exploration of everyday practice. Over time this facilitates a supervision context of safety and trust and a spirit of mutual respect and openness to be challenged.

In Charlotte’s case:

Supervision for those working with Charlotte would most likely acknowledge the long relationships staff might have had with the family and explore the impact of witnessing Charlotte’s parents’ differing desires about her treatment and death. The group may be encouraged to discuss how divergent points of view between very distressed parents over a gravely unwell little child commonly creates unhelpful splits in teams, where some staff become more sympathetic to one parent, or their baby, and clinicians within a team are pulled in divergent positions which mirror those in the family (Foster 2001). The discussion may highlight the impact of the death of child, when the death is unforeseen or where there has been an inability to plan and agree, including how this leaves not only the parents but also staff unprepared, often leading to feeling powerless and angry. Other feelings and responses that may be drawn out may include that some clinicians felt upset with themselves and/or others for not advocating more strongly for Charlotte. The supervisor would be curious about and specifically address why it was so difficult to raise a palliative care referral.

These types of discussion areas aim to both learn from the experience with Charlotte and support clinicians dealing with the difficulties at the time. How this may be undertaken in supervision is to acknowledge and to gain a deep understanding of clinicians’ responses to make room for the least appreciated perspective and to grow compassion and empathy where it previously may not have been possible.

One of the central tenets of clinical supervision is to help hospital staff recognize and accept the state of “not knowing”—not knowing all the facts, not understanding the parents’ differences or their motivations. Helping to provide clarity about salient aspects of the experience of Charlotte’s care and ultimate traumatic death enables the development of a coherent narrative (Siegel 2007). Developing more coherence about an experience serves three purposes. It can bring a sense of relief or closure to the experience. Secondly, it can leave practitioners feeling validated or supported. Thirdly, members of the team may have more confidence to be emboldened with future parents in similar situations.

The process of supervision may offer a shared space to mourn and honour Charlotte and her mother and father. The supervision might conclude with affirming the work and kindness of the team. It would aim to make sense of the life and premature death of Charlotte and the loss for her family—that it was Charlotte’s illness not “the hospital” that took her life. By talking collectively about what can feel unbearable, clinical supervision discussions assist teams and individuals to learn to bear more of the emotions that arise and to help others bear the limits of medical science.

Discussion

Each of the four reflective approaches discussed in this paper starts from the premise that each individual health professional potentially has emotional, psychological, and intellectual resources to think and act ethically, humanely, and reflectively (Lützén and Ewalds-Kvist 2013; Scher and Kozlowska 2018; Verkerk and Lindemann 2012). In each approach, the overall role of the facilitator is to orient participants towards their intrinsic resources so they can access and use them effectively. Each of the four approaches either implicitly (PFA, CISD, Clinical Ethics Review) or explicitly (Clinical Supervision) draw from psychotherapeutic techniques which can have adverse as well as beneficial effects (Shultz and Forbes 2014). Basic ground rules of the four models are that participation is voluntary, that discussions are to be mutually respectful and never intended as a performance appraisal, and that the facilitator understands their role and the potential beneficial and adverse impacts of their facilitation approach. The facilitation process involves purposefully creating a scaffold for participants’ thinking and reflection. The goals are to assist them to step back from an experience and identify their feelings, thoughts, and assumptions in order to make sense of and learn from their experience (Parlakian 2002). The effectiveness of reflective discussions within health profession teams relies on facilitators ensuring participants feel safe to reflect, share, and be open to exploring alternative perspectives that may sit in tension, allowing for a more nuanced discussion (Prentice et al. 2018). Coming together as a team enables validation of experience (Meziane, Ramirez-Garcia, and Fortin 2018), builds understanding, and promotes acceptance of moral discomfort (Imbulana, Davis, and Prentice 2021). This creates a space where specific ethical challenges, team dynamics, and specific unit-based environmental factors can be respectfully and constructively addressed (Morley et al. 2021).

This paper also highlights important differences in the guiding focus, timing, intended outcomes, and underpinning methodologies employed within these models. For example, the focus of PFA is constrained by what is needed for a person to move to a psychologically safe space. It purposefully does not seek to analyse the trauma or the events leading up to an event. The focus expands in CISD. Clinicians are encouraged to discuss and reflect upon, but also move beyond, a position of immediate safety so they can begin processing how the event has affected, or might later affect, their personal and professional functioning. Supported CISD discussions encourage participants to think about how they might effectively return to and work within the health teams and institution in which they experienced the critical incident (Schmutz et al. 2018).

In contrast, in both clinical ethics review and clinical supervision, the structure and purpose of the reflective discussion is less prescriptive. In both approaches, the aim is to open up and at times unsettle existing clinical, moral, and professional role frameworks (Newson 2015), offering the possibility of transformative learning (Mezirow 1991), where perspectives are challenged and new or revised understandings which might better explain a phenomenon are encouraged (Hartwell 2004). Given that the goal is to explore and challenge clinicians, the relationship between the facilitator and the group, or more accurately the level of trust a participant has in the facilitator, is central. Clinicians, as participants, need to trust the process and feel safe to contribute. Asking participants to bring their concerns and to identify what makes them feel anxious or worried in their work and then not having a framework or skills to acknowledge and support clinicians to process such feelings is potentially harmful (Emmerich, Gormley, and McCullough 2018; Rudolph et al. 2007). The onus is therefore on the facilitator to not only know what they are doing but also to recognize the scope and limitations of their specific approach within their skillset and anticipate what could go wrong.

All five authors work in a health institution where each reflective discussion approach is available some of the time. However, as with many large organizations, they are not yet offered in a coordinated, complementary, or systematic way (Boss, Geller, and Donohue 2015). For example, in a case such as Charlotte’s, requests from individual clinicians for PFA may occur. Others may organize a CISD and/or a clinical ethics review. In some clinical teams, where there is established clinical supervision support, Charlotte and her family may be discussed during a regular meeting.

This variation in what is offered to support clinicians following stressful events is common (Panagioti et al. 2017). In addition, whilst there is emerging evidence about the efficacy of such interventions, (Nordentoft 2008; O’Keeffe, and Shelton 2007; Shultz and Forbes 2014; West et al. 2016; Morleyet al 2021; Imbulana, Davis, and Prentice 2021) measuring the impact is notoriously challenging (Guidry-Grimes et al. 2019; Morley et al. 2021). The task of making an informed decision about which reflective discussion intervention to provide in a workplace or which approach to select for specific stressful events requires more empirical research about the effectiveness of interventions (Morley et al. 2021). It also requires clinicians, clinical leaders, and administrators to have a thorough understanding of the purpose of the discussion, who is best able to facilitate such a discussion, and what it is likely to achieve.

Conclusion

Being a health professional in an adult or paediatric health setting means inevitably encountering tragic situations. Every day, hospital clinicians face the reality of confronting the limits of medical science, as well as human tragedies and stressful events involving conflict, misunderstanding, and moral distress. Each of the four models of facilitated reflective discussion reviewed in this paper give clinicians, individually or collectively, a supportive experience so they know that they don’t have to bear the load alone. Each approach has the potential to provide clinicians with the critical thinking and reflection they require for processing and analysing ethically challenging clinical experiences, enabling them to flourish and grow professionally. Using these approaches wisely and safely benefits clinician growth and ultimately benefits patients and families such as Charlotte and her family.