Charge nurses are critical to ensuring safe and efficient unit operations, a smooth patient flow, and adequate staffing for a particular shift. They oversee patient care and serve as a resource for fellow staff. Because of increased patient acuity and shorter hospital stays, charge nurses have become increasingly crucial to high-quality patient care as well as patient and staff satisfaction. Despite the critical nature of their role, charge nurses have traditionally had little formal training to help them transition from clinical nurse to charge nurse.
This article describes the planning, implementation, and evaluation of a charge nurse initiative in a large academic medical center.
Our medical center doesn't have a permanent charge nurse model; rather, charge nurses are assigned on a rotating basis. Until this initiative, the role wasn't voluntary; all staff nurses were expected to assume the position if the need arose. The majority of staff new to the charge nurse position said they didn't have a clear understanding of the expectations for the role. Some units had their own charge nurse descriptions; other units had none. Orientation to the role was inconsistent and unstructured. The vice president of patient care services responded to these concerns and identified a project leader who coordinated a task force to determine issues and develop strategies to address them. The goals, as established by the task force, were to
* provide role clarity.
* clearly define responsibilities and core competencies.
* provide a formalized orientation.
* develop a standardized hand-off report.
A literature review provided guideines for identifying competencies and best practices for the charge nurse role. Although the role has existed in acute care hospitals for many years, much of the literature on the topic was published decades ago and few articles describe necessary competencies or give specifics about the position.
In 1977 Hinkle and Hinkle described the role of the charge nurse as overseeing patient care, providing complete and accurate documentation to minimize the potential for legal issues that might affect the hospital, and managing staff interactions.1,2 The authors stressed the importance of preparation for the role, with an emphasis on legal factors that can arise in the clinical setting. An article published in AJN two years later described challenges posed by a lack of preparation for the role as well as by a lack of authority.3 Focusing on the critical care area, Noll and colleagues identified essential elements of the charge nurse role, including the ability to ensure safe patient care, provide appropriate documentation according to hospital policies and procedures, and foster positive staff interactions.4 Lifson and Cantlon explained the process used to design, implement, and evaluate a standardized workshop for charge nurses.5 Duckett and Brunette described a modular educational program that clarified role expectations, increased charge nurses' knowledge of the hospital or nursing organization, and promoted leadership and management skills.6 Dubnicki and Sloan presented competencies to be used when selecting and training charge nurses.7
More recently, Connelly and colleagues described the results of a qualitative study regarding charge nurse competencies.8 Their presentation of skills, a variation of Katz's model from 1974, included four broad categories: clinical/technical, critical thinking, organizational, and human relations. They pointed out the important role that charge nurses play in determining the atmosphere and teamwork on a unit. In a subsequent article, Connelly and colleagues explained the importance of preparation through education and development programs, particularly for recent graduates.9
Krugman and Smith described the development and evaluation of a permanent charge nurse role.10 Outcomes of their study demonstrated the need for formalized management training, including sessions on communication and conflict resolution and the need for an end-of-shift report to communicate events and potential gaps in service that had occurred across shifts.
In 1999 Mahlmeister, who'd spent almost three decades reviewing medical records in nursing malpractice cases, reported that nurses were being increasingly scrutinized for their response to situations that could jeopardize a patient's well-being.11
A demanding, multifaceted role. According to the articles reviewed, the charge nurse role is one that calls for a multitalented professional who's technologically skilled and well versed in both unit and hospital policies and procedures. The charge nurse should have excellent interpersonal skills and be able to navigate the institutional system. Core competencies necessary for the role include assertive communication skills, and the ability to successfully manage people and difficult situations, think critically, make effective use of resources, and provide expertise in human relations. In addition to compassion, the charge nurse must possess conflict resolution and negotiation skills, and a basic understanding of personality and leadership styles. The role epitomizes professional resourcefulness and finesse at collaboration and team building.
IDENTIFYING THE ISSUES
Focus groups were held with representatives of different levels of staff familiar with the charge nurse role. Discussions in these groups revealed variability in criteria for the selection of charge nurses. For example, the experience level and characteristics of nurses selected by patient care directors for the role were inconsistent. Participants agreed that charge nurses needed to be competent, possess effective communication skills, be collaborative, have good decision-making skills, and be able to work well under pressure.
Variability in assignments was also discussed. On some units, the charge nurse had a minimal patient load, while on others she or he had a full patient assignment. Staff felt that the charge nurse role, when coupled with a full patient load, was often difficult and unfulfilling.
The method of communicating shift report also differed from unit to unit. Basic components, such as census, acuity, and emergencies, were considered standard, but additional areas of information were identified by leadership as requiring a revised and standardized shift-to-shift follow-up report.
Some charge nurses were oriented by their patient care director, while others were trained by senior charge nurses. The length of orientation varied and there was no consistent training across units.
A quality improvement team was formed to resolve the identified issues. Members of the team, who were chosen from all levels of nursing, were asked to develop solution and action plans. Each participant was asked to sign up for one of the following teams.
Charge nurse role, criteria for selection, and workload team. This team defined the charge nurse role and made it consistent across all units. Criteria for selecting charge nurses were developed. Criteria included clinical experience, an ability to lead a group, and effective communication and collaboration skills. A sample of the role description and criteria for selection is included in Charge Nurse Role and Responsibilities.
The team recommended scheduling nurses to be in charge on consecutive days to ensure continuity. Whenever possible, consistent with staffing needs, charge nurses were to be given a modified patient care assignment.
Charge nurse competencies, accountabilities, and unit-specific standards team. The goal of this team was to organize competencies into a framework to facilitate implementation. The model used was described by Connelly and colleagues,8,9 with core competencies in four categories:
* critical thinking
* human relations
Each competency was correlated to the hospital's strategic initiatives so that nurses could see how their work reflected those initiatives. For example, clinical and technical skills were linked to the hospital's organizational goals of quality, safety, and "people development." Other examples are included in Charge Nurse Core Competencies.
This team decided it was imperative to develop a standardized report to ensure consistent communication from shift to shift. A hand-off report for charge nurses was developed that included all the required elements to pass on when communicating with the on coming charge nurse. Essential elements included admissions, transfers, discharges, and patients going to the operating room, as well as quality issues such as falls, restraints, unusual incidents, medication discrepancies, isolation, close observations, drips, telemetry, and pressure ulcers. Sections were also included for items to be checked or monitored (for example, crash cart, glucometers, central lines) and for patient and family needs and concerns (to see the hand-off report, go to http://links.lww.com/AJN/A13).
The team felt strongly that having a charge nurse competency checklist would standardize skills for nurses who were being oriented to the role. A portion of the competency checklist can be found at http://links.lww.com/AJN/A14.
Orientation and support/resources team. This team identified recommendations for a charge nurse orientation workshop. Although, ideally, nurses should attend the workshop prior to being in charge, the decision was made to initially target nurses who had less than a year's experience in the charge role. The overall goal of the workshop was to provide guidelines for decision-making processes, thus helping new charge nurses build confidence in their ability to manage the challenges of the role. This orientation was to be followed by a unit-specific orientation facilitated by the patient care director and/or an experienced charge nurse.
The team recommended that each section of the orientation be facilitated by management staff. Managers have a vested interest in participating in the program and making it a success; they want well-prepared charge nurses who can manage units smoothly and effectively.
The suggestion was made to provide a reference manual, "Charge Nurse Roles and Responsibilities," that would be available on all units.
THE ORIENTATION WORKSHOP
Interactive case scenarios. A major outcome of this initiative was the development of a standardized orientation workshop. The traditional classroom lecture format was replaced by a workshop format because the interactive process that occurs in a workshop is more conducive to networking and openly sharing experiences and viewpoints.
Charge nurses were asked to identify real-life case studies that had occurred on the clinical units. Clinical experts reviewed these situations and identified appropriate responses. These responses were compared with best practices and checked against hospital policies and procedures prior to approval for inclusion in the workshop. Case studies were included for the following topics: chain of command, staffing, making assignments, challenging patients and families, conflict resolution, emergency situations, and service recovery. The case scenarios were designed to be interactive and practical for everyday operations. For a sample case study see Case Study: Staffing/Assignments.
Workshop facilitators. Directors, patient care directors, clinical managers, supervisors, nursing instructors, and staffing coordinators volunteered to lead each topic. Having managers facilitate sessions reinforced their commitment to the charge nurse role and also provided in-depth expertise for the discussion of individual issues.
A three-hour facilitator orientation was held prior to the first orientation workshop. This orientation included an overview of the program content and goals, findings of the focus groups, and recommendations for conducting the workshop. Scenarios were discussed as well as key points regarding responses. Discussion of the facilitator role, skills required for facilitating a group, and how to deal with challenging participant situations were also included. Facilitators had an opportunity to provide input and to ask questions regarding expectations.
The charge nurse workshop started with an overview of leadership and personality styles, followed by a review of role guidelines and an exercise involving core competencies. A discussion of effective communication techniques and conflict resolution included a case study on communication. For the remaining morning sessions, participants were divided into small groups. One member was given the task of writing strategies to resolve the scenario on a flip chart. Another was asked to present the group's strategies to the larger group. Responses to case studies were then reviewed and key points for the most effective strategies were reinforced by facilitators. An open exchange of ideas and an opportunity for discussion with management offered the staff a forum in which to question actions and the principles behind those actions. At the end of the day, the program was summarized and participants were given an opportunity to share feedback. The day ended with the participants completing an evaluation of the program. In the first year, the workshop was conducted for eight consecutive months, with 108 nurses attending.
Workshop evaluations were extremely positive, with 88% of participants giving the program the highest rating. Novice nurses appreciated having an opportunity to experience the benefit of working through real scenarios with their peers in a collaborative and safe environment while in the presence of patient care leadership ("It was extremely helpful to practice critical thinking skills with real-life situations that were facilitated by our managers"; "The interactive approach using case scenarios and telling our own experiences really helped"; "The workshop raised issues I hadn't considered before"; "The workshop clarified what is expected of me. I found out the role includes responsibilities I never thought about"; "The case studies helped me develop my problem solving skills"). Participants stated that the case scenarios helped them understand the expectations of management. They also reported that the workshop facilitated networking with staff from other departments ("It was an interesting and eye-opening experience, as it gave me insight into how other units work and offered a different perspective on situations that occur on my unit").
There were suggestions for improvement. Some participants stated that there were too many scenarios and thought it might be helpful to do some role playing. As a result, role playing has been integrated into the program (for a role-play exercise, go to http://links.lww.com/AJN/A15.)
A focus group with facilitators was conducted after eight months to share the evaluations of participants and elicit feedback regarding facilitators' experiences with the program. Facilitators were extremely supportive of the program and stated that it provided nurses with a clear understanding of the charge nurse role. For many of the facilitators, listening to the staff was a learning experience. They enjoyed both the sharing and the teaching aspects of the case study format. Based on the focus group's comments, the order of the program and allotted times for topics were adjusted. In addition, other managers offered to become facilitators. The commitment to and enthusiasm for the program are strong.
One year after the start of this initiative, focus groups were held with directors, patient care directors, supervisors, staffing coordinators, and staff to evaluate how effective the program had been in helping charge nurses in their role. Questions were asked regarding the effectiveness of the orientation, support for charge nurses following orientation, work load for nurses when they're in charge, consecutive days in charge, and communication. A summary of these comments follows.
Qualitative experience of charge nurses completing the course. All nurses interviewed six months and one year after attending the charge nurse workshop stated that the workshop was extremely helpful. This was especially true in identifying both the expectations of the role and the steps to take when solving the problems they were frequently confronted with in clinical situations. Nurses reported that they knew whom to call, that is, the chain of command, as well as when and how to access resources. In addition, the competency checklist provided specific information on the skills charge nurses are expected to have. All nurses reported that they felt prepared and confident about performing in the role. Patient care directors and supervisors confirmed that charge nurses now exhibited more confidence.
Support for charge nurses following orientation. Although there's no formal mentoring process for charge nurses, patient care directors provide support and are a resource on a daily basis. Efforts are being made to develop a more formal mentoring process.
Workload. The goal is always to avoid giving the charge nurse an assignment. When this isn't possible because of inadequate staffing, modifications are made in the charge nurse's patient assignment. These modifications could include fewer patients, less acutely ill patients, and patients whose rooms are located near the nurses' station.
Consecutive days in charge. On average, nurses are in charge on two to three consecutive days to enhance continuity of patient care. The number of consecutive days is determined by the fact that nurses work 12-hour shifts three days a week.
Communication. The hand-off report has standardized information communicated from charge nurse to charge nurse and shift to shift. According to all those interviewed, communication via the hand-off report is more consistent, timely, and thorough.
When asked about communication regarding unusual events that occur on the unit, patient care directors, supervisors, and staffing coordinators reported that charge nurses who've attended the orientation workshop communicate more effectively and tend to take the initiative and follow up on issues. This is in contrast to the previous approach of telling the issue to the patient care director, who would then do the follow-up. Nurses now also document information and send it to the appropriate person.
The competency checklist and hand-off report provide nurses with the skills, tools, and confidence to successfully perform the charge nurse role. A standardized charge nurse orientation is also essential, especially for nurses who are new to the role or who are assuming the role in a clinical area that's new to them. An orientation based on real-life case studies that are interactive and experiential is more conducive to learning than an orientation using a didactic format. In addition, having educators, managers, and supervisors facilitate sessions can lead to discussions of related issues that might not occur in a lecture format. A consistent comment on the program was that nurses valued the opportunity to work on decision-making skills in a safe environment. Feedback from novice and experienced charge nurses, managers, supervisors, and educators was instrumental in the success of our program. Group process that involved all levels of nursing increased the commitment to the initiative.