Abstract
Nurse related adverse events occur not because nurses intentionally hurt patients, but rather that the
health care environment is so complex that outcomes for each patient are affected by a range of factors
and not just the competence of an individual nurse. Effects of the “sharp end’ where nurses find themselves
being vulnerable to errors occurring must be removed from nurses and put squarely on the
shoulders of the nursing leadership who must focus on systems factors, not individual nurses to blame,
as a strategy to constructively manage nurse related adverse events. The purpose of this study was to
explore and describe the experiences of operational managers (Unit Managers) regarding the management
of nurse related adverse events by their line managers in a regional hospital in Gauteng, South Africa.
A qualitative, exploratory, descriptive and contextual research design was used. A purposive sample
of operational managers working in the specific hospital who had experienced the management of nurse
related adverse events by their line managers and willing to participate was selected for the study. Data
collection was by means of in depth phenomenological individual interviews and data were analysed by
the researcher and an independent coder using Tesch’s open coding method .The findings revealed that
operational managers experienced a culture of blame during the management of nurse related adverse
events with suggestions for development of nursing leadership strategies that focus on a blame free just
culture to facilitate the constructive management of these events.