Hospital Staff Nurses' Experiences With Having had a Sentinel Event

Title of Poster

Hospital Staff Nurses’ Experiences with Having Had a Sentinel Event

How the Pilot Study Fits with the Meeting Topic of Creating Healthy Work Environments

The topic of the pilot study, Hospital Staff Nurses’ Experiences with having had a Sentinel Event fits with “Creating Healthy Work Environments” in that the purpose of the study was to understand how the work environment may influence sentinel events.

Purpose of the Pilot Study

A pilot study was conducted over the months of May through June 2018 with five registered nurses from various hospital settings. The purpose of the pilot study was to begin to develop an understanding of nurses’ experiences with sentinel events in the hospital setting in order to assist nurse leaders in creating and sustaining healthy work environments.

Significance

For the years 2005-2017 The Joint Commission reported 67% of all reported sentinel events occurred in the hospital setting (2018). Sentinel events for the years 2005-2017 claimed the lives of 5,826 patients with an overall total of 11,189 patients impacted in some way (The Joint Commission, 2018). While quantitative information is known about sentinel event numbers, little information is known about nurses' perceptions of sentinel events. Understanding nurse perceptions may lead to both the prevention of sentinel events as well as needed workforce environment changes to support nurses after these events.

Methods

For this pilot study, a qualitative descriptive phenomenological approach was used for datancollection and analysis in order to capture the human experience through interviews with participants (registered nurses) who had experienced a sentinel event (Creswell & Creswell, 2013). Five registered nurses were recruited using purposive sampling through social media. One on one open-ended interviews were conducted. Data analysis followed Munhall’s (2012) conceptual model of phenomenology that explored the uniqueness and the human experience of each participant.

Results/Findings

Data analysis revealed two overall themes: (1) Failures of the work environment where participants noted the work environment was not a welcoming one and the nurse’s problems were the nurse’s problems to be dealt with. (2) When emotions, feelings, and behaviors impact practice and personal life where participants noted they were afraid they were going to make another mistake and some participants changed job positions or considered changing departments all together.

Discussion/Implications

The pilot study identified that the nurse’s work environment often is not a favorable one for those who make errors, and when an error is made, there is lack of support from leadership in moving past the event. The study identified factors that contribute to the occurrence of sentinel events, such as nurse staffing issues, nurses’ not being heard, and novice nurses being placed in leadership roles. Additionally, the pilot study revealed factors that impact the nurse’s personal and professional life, such as an unfavorable work environment and the lengthy process of investigation that is endured after one experiences a sentinel event (constant reliving of the experience). More research is needed to further explicate what the barriers and facilitators are to creating a supportive work environment that supports the nurse who experiences a sentinel event.