Date of Graduation

Spring 5-18-2023

Document Type


Degree Name

Doctor of Nursing Practice (DNP)


School of Nursing and Health Professions




Executive Leader DNP

First Advisor

Dr. Mary Lynne Knighten

Second Advisor

Dr. Sara Horton-Deutsch


Using Critical Incident Debriefing after Code Blue Events to Support Registered Nurses

Section I: Abstract

Background: During a code blue event (CBE), the environment becomes highly stressful and intense. Nurses rapidly transition from performing life-saving procedures on their patients to carrying out their usual duties. Without proper debriefing, nurses cannot properly process their emotions leading to increased burnout and secondary traumatic stress (Stamm, 2010).

Local Problem: In 2021, the nurses at Providence Saint John’s Health Center (2021a) responded to 110 CBEs, a 43% increase from 2020. Without a process for critical incident debriefing (CID), these nurses were exposed to trauma at each event without support for their psychological well-being.

Methods: This quality improvement change project occurred at a community hospital in Santa Monica, California (July 2022 through January 2023). It used a pre- and post-implementation design to determine if CID changed nurses’ professional quality of life survey scores.

Interventions: Interventions for this project included conducting a survey pre- and post-implementation of education on CID and implementing a formal debriefing process for CBEs.

Results: Eight-one nurses participated in this project’s survey. Eighteen nurses completed the pre- and post-implementation survey. No statically significant changes occurred in the nurses’ levels of compassion satisfaction, burnout, or secondary traumatic stress.

Conclusions: Implementing debriefing at PSJHC supported nurses involved in CBE. Several limitations exist, but the project overall supports CID. PSJHC should consider the formal adoption of this CID process.