Changing a leadership structure when patient care outcomes are at stake could be considered a leap of faith and optimism by the nursing executive team, or a desperate action to meet new bottom-line fiscal imperatives. The literature reflects the struggle by many acute care facilities to find the right leadership pattern to assure safe and favorable patient outcomes. Some leader roles seem familiar when closely examined, reflecting new titles for types of personnel already known to provide similar functions described earlier in the literature. Titles of positions such as coordinator or team facilitator seem similar to the historical roles of charge nurse and team leader.
When UCH nurse leadership reviewed the evidence related to nursing management structures, the process was generated by many considerations. We desired to change the composition and type of nurse leaders in our department’s self-governance structure to reduce both the numbers of separate clinical divisions and layers of management. We also thought it made sense to pair units offering similar services or service lines, to improve the flow of patient care continuity.
Finally, we hoped to gain greater line authority over clustered services by converting managers to directors. While fiscal savings were gained by reducing numbers of managers, the decrease in these salary dollars was offset by the higher salary dollars required for director-level positions. After reviewing the available literature, we decided to develop a charge nurse job description, and create permanent charge nurse positions for each shift. The charge nurses reported to clinical directors, who in turn report to the vice president of patient services and chief nursing officer of the hospital.
Review of the Literature
Although the charge nurse role has been well established in many acute care hospitals, there are surprisingly few articles written about how the role was initiated, its structure, or its effectiveness or the relationship of the role to nurse managers or directors. A review of the historical literature on charge nurses documents the role. In one of the first reported articles, a two-part series, Hinkle and Hinkle described the charge nurse role, with special emphasis on legal implications of being in charge. 6,7 Meredith described how to be charge nurse for a day in 1979, identifying the potential problems for those assuming the daily responsibility when inexperienced. 8 Noll et al 9 identified some of the problems associated with the role, including holding the responsibility without the authority, no formal job description, no increase in pay for the additional work, and no formal education for the role.
More recently, Osguthorpe 10 outlined the role of the charge nurse in the critical care unit, noting the existence of both formal (permanent) and informal (relief) charge role patterns, defining the charge nurse as having designated leadership and management accountability for a shift. She identified and described the desired competencies of charge nurses using Dubnicki and Sloan’s 11 leadership competencies framework: achievement, management, interpersonal relations, problem-solving, and personal performance. Karpiuk et al 12 reported changing the rotating charge nurse role into a clinical coordinator position, to address some of the issues Noll had discussed years earlier.
Bostrom and Suter 13 conducted one of the few existing research studies on charge nurses, examining leadership decision-making and patient assignments. Their results showed charge nurses often did not follow the acuity systems in making assignments. The complexity of the assignment process was impacted by the degree of charge nurse years and experience in practice, situational factors on the units, and how the charge nurses did or did not value patient and nurse preferences in the making of assignments.
Ambrose 14 delineated the criteria for selection and orientation of charge nurses, after interviewing 30 staff nurses about their perceptions of the role. Costello-Nickitas 15 described how the nurse assuming a temporary charge nurse assignment could employ strategies to be successful, including reviewing expectations, planning, incorporating strong communication skills, and reflecting on performance post shift.
Educational programs for charge nurses were described by Lifson and Cantlon, 16 Spickerman et al, 17 Duckett and Brunette, 18 and more recently Cartier 19 in 1995. Education for charge nurse leadership in these articles included content on the role of the charge nurse, leadership theory, communication, delegation, conflict resolution, and other topics such as stress management. Cartier 19 notes that it would be of interest to know if peer and subordinate perceptions of charge nurse leadership behaviors changed after taking such a course, asserting that leaders are not born, but are developed through formal education and coaching.
In summary, the charge nurse role has been a part of the nursing management structure for over 20 years in many acute care institutions, proving its durability over time as a role that provides service to the daily management of patient care, although not without identified issues related to how this role is structured and implemented. Regardless of potential problems, nurses who have been in this role have described how it provides the staff nurse with an opportunity for development of leadership skills, and a potential career path toward a position of increased management responsibility.
University of Colorado Hospital Charge Nurse Leadership Project
In 1995–1996, representatives of nursing leadership formed a task force to initiate the process for establishing a permanent charge nurse leadership position. The Task Force defined the role by creating a job description, delineating the position as a delegated leadership role with responsibility for the daily unit management, continuity of care, quality patient care standards, and support for the development and performance of staff.
Two characteristics distinguished the permanent charge RN from the role of relief charge: (1) the increased responsibility for groups of employees, including conducting performance evaluations and disciplinary actions under the supervision of the director; and (2) accountability for specific permanent leadership responsibilities such as chairing unit committees, payroll, and managing the staff schedule. Additionally, at UCH the charge nurse positions were created across shifts 7 days per week, covering days, nights, and weekends. Although permanent charge nurses do not hold direct budgetary responsibilities, they are designated as the control authority over such issues as ordering supplemental staff, assuring bed control functions, patient classification such as observation status designation, and accurate census management, which are functions tied to the billing system.
The charge nurse position was viewed as a promotional opportunity, and placed at a grade above the staff nurse position but maintained as nonexempt status within the human resources system. Nurses had to apply in a competitive process through position job postings, complete a supplemental application consisting of short answer essays, and participate in interviews with the clinical director and staff nurses.
The project’s theoretical framework is Kouzes and Posner’s Leadership Model. 20 This model uses five domains to represent the dimensions of outstanding leadership behaviors: Challenging the Process, Inspiring Shared Vision, Enabling Others to Act, Modeling the Way, and Encouraging the Heart. These domains capture the essence of leadership and speak to the actions and activities of leadership that are easily understood by the charge nurses and nursing executive team.
The project was implemented in June 1996, with 104 permanent charges hired into the new positions. Baseline data were collected pre-program initiation, and then a 2-day training workshop conducted to orient the permanent charge nurses to the expanded role and increased leadership responsibilities. The content of this training included components from the literature on charge nurse leadership education, as previously described. Over the years of this project, data outcomes have informed the nursing directors of gaps in charge nurse role functioning, and provided guidance for executive decision-making to further strengthen the charge nurse leadership role and structured continued leadership training.
Charge Nurse Leadership Program Evaluation
The evaluation framework for the charge nurse leadership program was constructed as a research study, with institutional review board approval and human subjects consent procedures incorporated into study methods. Each of the methods chosen to measure the success of the four primary objectives (Table 1) required different approaches to data collection. The first objective, to develop charge nurse leadership skills, involved using survey research methods with the charge nurses representing the convenience sample. The second objective, to improve unit functioning, was measured using an investigator-developed End-of-Shift report based on the 11 functions of the Joint Commission for the Accreditation of Healthcare Organizations, 21 which permitted UCH to not only review the effectiveness of the charge nurse role, but also systems issues that may require a performance improvement process.
The third objective, nurse job satisfaction, was tracked by survey research methods using the McCloskey-Mueller Satisfaction Scale (MMSS, 1990) 22 as a part of UCH longitudinal data collection of professional registered nurse job satisfaction. The fourth objective, maintaining patient satisfaction, proved to be the most challenging data to collect and analyze, since over the 6-year period the institution changed companies and methods for collecting these data. These changes significantly impacted the utility of these data.
Charge Nurse Demographics
The charge nurse demographic profile did not change over the 6 years of data collection and study, with the exception of number of permanent charge nurses studied, which decreased from 104 to 80 over the time period. The permanent charge nurses are a stable group of seasoned nurses who are primarily Caucasian (90%) women (92%), with more than 50% in practice more than 15 years, over 50% at UCH more than 6 years, and on their current unit more than 3 years. More than 70% work full time, while 78% of respondents hold a baccalaureate, masters, or a nursing doctorate degree. The remainder of the charge nurses, 22%, were enrolled in a BSN program, an expected finding since one of the requirements of the program and the UCH Professional Practice Model, UEXCEL, is that nurses in the charge position not holding an earned baccalaureate nursing degree must be enrolled in this educational level within 2 years of hire into the position. The demographics of UCH charge nurse sample are representative of the overall population of professional nurses at UCH.
Objective One: Improve Charge Nurse Leadership
The Kouzes and Posner 23,24 theoretical framework incorporates five fundamental practices of exemplary leadership, each delineated by major commitment statements to provide a guide for the desired leadership behaviors, called the Ten Commandments of Leadership.
These domains serve as the construct for the Kouzes and Posner’s Leadership Practice Inventory (LPI), the instrument used to measure charge nurse leadership. 23,24 The LPI was selected as the preferred instrument because it provides concurrent measurement of both charge nurse reported perceptions of leadership abilities and staff perceptions of charge nurse leadership abilities.
The LPI is a 30-item Likert style scale, ranging from 1 (low) to 5 (high), with a range of summed scores from 30 to 150. Kouzes and Posner’s method of test administration consists of matching a “Self” subject with “Other(s),” or observer subjects. The instruments have been tested for reliability and validity by over 36,000 multinational subjects, many from business backgrounds, with a reported Cronbach’s alpha range of between .70 and .85 for the Self instrument, and between .81 and .92 for the Other version. Due to the methodological constraints of matching the volume of UCH respondents in both the Self (Charge) and the Other (Staff nurse) groups, matching individual respondents was not feasible. The subject groups were therefore treated as aggregate unit level of data. The Cronbach’s alpha for the UCH charge nurse subjects is .92, and for the staff nurse group is .97.
While there has been less extensive reported use of the LPI on health-related professional groups, use has been documented with nursing populations. McNeese-Smith 25 used the LPI to measure staff nurse satisfaction with nurse managers, reporting positive associations with the domain, Encouraging the Heart. In England, Bowles used the LPI to compare outcomes between two units, one with transformational leadership and the other conventional management. 26
Standard survey methods were used each timed data period to disseminate and collect data using the LPI for both charge nurses and staff, including informed consent. At baseline, it was anticipated that both charge nurses and staff would perceive charge nurse leadership to be low to moderately scored on the scales, and over time results would report incremental increases by both groups in charge nurse perceived leadership success.
Results and Analysis of Leadership Practice Inventory
There were no significant differences between charge nurse demographics and their responses on the Leadership Practices Inventory (LPI). However, baseline LPI results showed a significant gap between how the charge nurses perceived their leadership abilities, and the perceptions of the staff. The charge nurses were significantly more positive in their self-reported leadership abilities. This was a surprising finding, since we had anticipated moderate ratings at baseline as the new permanent role was initiated. Charge nurses immediately perceived themselves as successful leaders in the role, perhaps because they had served as relief charge nurses. Staff nurse perceptions of Charge leadership were clearly less highly rated. This gap fluctuated over the four timed data collection periods. A summary of data results by years, including response rate, mean scores, standard deviation, and range can be reviewed in Table 2.
After baseline and first-year results were compared, and the initial gap was recognized, nursing leadership implemented strategies to enhance charge nurse leadership functioning. An emerging self-governance council was consolidated, and two sessions of continuing education were included at these meetings, focused specifically on communication and conflict resolution. With the third timed data collection, results indicated the gap in perceptions to be a trend. The Charge Nurse Council was further strengthened, and formal leadership training was initiated in conjunction with Human Resources. Charge nurses were assigned to attend the hospital’s management leadership program that had previously been open only to upper level management.
This most recent intervention, formal management training, seemed to improve many dimensions of charge RN and staff perceived leadership ratings. In 1999, increased turnover of charge nurses due to national attrition (move, birth, marriage, other) appears to have impacted staff scores in 2000. Statistical analyses of aggregate mean scores were compared over the time periods using one-way analysis of variance (ANOVA) reported significant differences (F = 13.88, df = 5, P = < .001).
Domain scores reported significant variability over time. Charge nurses improved on specific domains in 2000 when the aggregate mean score of 2000 were compared to the overall aggregate mean score from all other years using t-tests: Inspiring a Shared Vision (t = −2.26, P = .02) and Challenging the Process (t = −3.18, P = .002). It was encouraging to see charge nurses improve on questions related to philosophy and values, such as “I am clear about my philosophy” and “I let others know my beliefs,” since the vision domain had proven difficult for charge nurses. Role functions requiring them to take actions and make decisions have been areas of greater reported skill and comfort level than visionary concepts.
While charge nurses reported improved perceptions of their ability on Modeling the Way (t = −3.18, P = .002), staff perceptions of their ability in this domain declined significantly over time (t = 2.52, P = .01). Staff also reported a decline in 2000 in the domains Encouraging the Heart (t = 2.35, P = .01) and Enabling Others to Act (t = 2.52, P = .01). The numbers of charge nurses new to the role increased during this time period, a potential factor in the decline of these scores.
Significant variation in staff and charge nurse scores were reported across clinical units (Figure 1). Data have helped directors and charge nurse teams focus discussion on what unit issues were potentially impacting charge nurse leadership success. The charge nurses, who hold varying degrees of leadership ability depending upon level of experience, personal characteristics, and ability to manage ambiguity and unanticipated problems, represent one source of score variation. However, we also realized another potential source of variation, the director’s leadership abilities. Lack of data on both charge and staff nurse perceptions of director leadership is a limitation of this project.
Objective Two: Improve Unit Functioning
Documenting shift-to-shift events, or some type of end-of-shift reporting, is a common activity for charge nurses, and is referred to generally in historical literature as a widely accepted role responsibility. 27,28 For the purposes of this project, the end-of-shift report served not only as an internal unit-focused communication tool, but also as a mechanism to report systems issues facing the new charge nurse, as a record for the director to use to evaluate how the charge nurses functioned, and to trend problems and drive performance improvement activities.
The UCH End-of-Shift Report was developed by author Smith, in collaboration with the Charge Nurse Task Force. It was built using the structure of the 11 functions of the Joint Commission of Accreditation of Healthcare Organizations (JCAHO). 21 These functions included the following categories of organizational performance: Patient Rights and Organizational Ethics; Assessment of Patients; Care of Patients; Patient Education; Continuum of Care; Leadership; Management of the Environment of Care; Management of Human Resources; Management of Information; and Surveillance, Prevention, and Control of Infection. After a trial period, the numbers of categories were reduced to the following: Patient Rights and Organizational Ethics; Care of Patients; Continuum of Care; Management of Information; and Leadership. The 14 inpatient units who hired permanent charge nurses participated in the shift-reporting component to measure unit functioning.
The method for this data collection consisted of unit leadership first reviewing the shift report, then forwarding to a centralized location for entry. Data were analyzed by JCAHO shift functions, and reports generated for units and nursing leadership to use as the basis for improvements. At baseline, the focus was on reporting the broad picture of what events occurred across shifts, and how issues were similar or different by service. As the project unfolded, the number of reported issues declined, the result of targeted interventions to improve systems processes and improved charge nurse unit management.
One particular issue identified as problematic early in the project was pharmacy services. Information was trended on medication delivery problems, identifying the subcomponents of the problems. Delays in delivery of medications were a top medication supply issue. The vice president for patient services, as the chief nursing officer, took an advocacy role to spearhead improvement. Nursing and pharmacy personnel joined forces to work with engineering to redesign the pneumatic tube system, initiate a new satellite pharmacy in the intensive care units, hire a special pharmacy transport “runner,” and reduce numbers of unit stock drug trays on the intensive care unit. Additionally, the pyxis system was reviewed and improved in relation to stocking and arrangement of items.
Supplies, staffing, medication delivery problems, information system downtimes, and patient complaints were specific issues that declined over the first 18 months of the project, due to focused interventions by nursing leadership and improved charge nurse coaching to better manage daily unit issues. Trended data were used to compare and contrast unit issues. Directors then had an opportunity to work with charge nurses on data specifically tailored to their unit profiles. Over 1200 shift reports were entered into the database, and trends generated.
As our hospital moved to an online documentation system using nursing intervention classifications and outcomes, data were more readily available on patient outcomes through computerized printouts, permitting charge nurses to review data concurrently with greater access and ease. While the end-of-shift report now looks very different across services, the original format proved to be an excellent method to identify the issues requiring process improvement. Perhaps the most valuable aspect of this research objective proved to be the positive impact of data on charge nurses’ image and self-esteem. For years, as relief charge nurses, they had expressed frustrations about systems issues, but did not have data to support their concerns. With shift data, complaints and frustrations could be channeled into action plans, and charge nurses were empowered to participate in changes. The active leadership of the chief nurse executive lent significant weight to the resolution of the issues, and provided a positive role model for best practices in managing administrative issues.
Objective Three: Maintain Patient Satisfaction
This objective, to measure patient satisfaction outcomes, was originally planned to be quite simple, using data obtained from a common nationally used patient satisfaction instrument. However, the instrument used to measure the hospital’s patient satisfaction changed during the 4 years. Data were also reported differently with each instrument. Therefore, this project objective could not be measured accurately enough to either report or relate to the measurement of the permanent charge nurse role functioning.
Objective Four: Nurse Job Satisfaction
The task force wondered how both the charge nurse and staff nurse job satisfaction would be impacted by the change in role. Job satisfaction of the registered nurse on the team is essential to a smoothly functioning acute care enterprise. Additionally, this model meant the director role changed from a “hands on” management role to a more consultative and mentoring role with the charge nurse. Questions were raised about whether the care provider team would accept the charge nurse authority, and how comfortable the charge nurse would be with this increased level of responsibility.
UCH has collected data on registered nurse job satisfaction since 1992. It was decided to track future data collections by a question asking whether the respondent was functioning in a permanent charge nurse role, and analyzing the comparison outcomes by groups. Job satisfaction data have been collected using the McCloskey Mueller Satisfaction Survey (MMSS, 1990), a Likert-type 31-item self-report scale, measuring job satisfaction from high to low on a 5-point scale. The instrument has eight nurse-sensitive dimensions, with a range of mean scores from 31 to 155, and a Cronbach’s alpha of .89.
Results of UCH nurse job satisfaction can be reviewed in Table 3. There are significant differences in score results across time periods when tested using ANOVA procedures (F = 4.81, df = 4, P = .001). Job satisfaction dropped significantly in 1996–1997, the first year of the charge nurse program. However, this decline cannot be linked directly to the charge nurse role functioning because at the same time, significant changes occurred in the nurse executive team and in nurse salary benefits. The strong upturn in satisfaction scores in the next year were also most likely not associated with the charge nurse role, but instead to a new CNO and a restoration of more favorable nursing salaries. The complexity of intervening environmental variables means staff nurse job satisfaction cannot be directly associated with the way charge nurses function in their leader role.
However, the charge nurse rate of job satisfaction could be directly measured. In 1999, the first year of coding charge nurse respondents, there were no significant differences between the job satisfaction of charge nurses and the job satisfaction of clinical staff nurses. However, in 2001, charge nurses self-reported job satisfaction was significantly higher than staff nurses on three of the eight subscales: satisfaction with schedule (t = 2.6, P = .009), praise and recognition (X2 = 4.72, df = 1, P = .03), and control and responsibility (X2 = 4.38, df = 1, P = .03), domains relevant to the role of the charge nurse.
Evaluating the leadership development program for UCH permanent charge nurses has provided a rich source of knowledge and data about the process and insights of lessons learned. It has been rewarding to see charge nurses grow and develop, yet challenging to realize the time and effort it takes to build emerging nurse leaders. Each charge nurse comes into the role with a unique background and traits that impact the management of the particular service or unit. And conversely, each of the directors brings to the leadership mix their own style of leadership, coaching, and team building. Although the process is rewarding and important for building succession, we have learned it is a significant level of commitment and more labor intensive to work with six or eight charge nurses across shifts than with one unit manager.
The gaps in perceptions between charge and staff on the Leadership Practices Inventory in part reflects the challenges of this development commitment, and highlights the complex interplay between director, charges, and staff. Our directors in this leadership model hold the responsibility for coaching charge nurses into a high-performance team across shifts and over 7 days of the week, so reporting charge nurse leadership scores as an aggregate group reflects this project objective. Three components of program development have made a significant difference in the success of how well this leadership model has been sustained in the UCH nursing structure: (1) A consistent hiring process, using standardized interviews questions and materials; (2) A structured orientation, including competency checklist; and (3) Implementation of the charge nurse Leadership Council. Each of these dimensions has contributed to strengthening the process over the 5 years.
One part of program development that still needs constant and additional improvement, however, is the role of the charge nurses in evaluating staff. From qualitative evaluation data collected on UEXCEL, our clinical advancement ladder program, some staff nurses expressed dissatisfaction with how their evaluations are conducted. Although charge nurses do attend a Human Resources class on performance appraisal management, the actual “lived world” of the evaluation encounter requires experience with the process. This is an area for further review and ongoing improvement, and illustrates how evaluation data from one aspect of department operations can be used to illuminate issues in another dimension.
During the past 5 years, the UCH permanent charge nurses have become a highly professional group of nurse leaders, respected within the institution by departments and physicians. Charge nurses who have been in the program from its inception feel very strongly about the value of this role, and the integrity of the process. Recently, when one of the UCH specialty service line divisions had a change of director-level leadership, several proposals were made to reconfigure the leadership structure to have one of two of the specialty areas within the division hire a manager. The staff nurses and charge nurses firmly and clearly turned down these offers, desiring to maintain the present system so the reporting structure would not add an additional layer of management.
The UCH charge nurse leadership project has proven to be an important initiative for our hospital. We have created a generation of nurses at UCH more empowered and satisfied with their positions, and in the process created a promotional opportunity within our clinical ladder as well as a system for management succession. The LPI has provided significant data for use in guiding improvements, such as recognizing the need to formalize management training with Human Resources. The End-of-Shift Report provided insights into significant systems issues, with data providing affirmation of charge nurse concerns about gaps in service at the point of care. And finally, we have all learned how this process requires a significant commitment on the part of nurse leaders to manage coaching and development, a worthwhile effort to create the next generation of nursing leaders.
The authors thank the Charge Nurse Task Force, led by Kathy Boyle, MS, RN, Chair, for initiating the Leadership Model; Colleen Goode, PhD, RN, FAAN for sustaining it; and the UCH charge nurses for their dedicated leadership, under the guidance of Marge Frueh, MS, RN. The authors thank Tom Miyoshi for data entry and statistical support.
© 2003 Lippincott Williams & Wilkins, Inc.