Institute of Medicine (IOM) recommendations call or promoting leadership at the point of care and enhancing competencies at all levels.1 Core measures, hospital-acquired conditions, never events, National Patient Safety Goals, and Hospital Consumer Assessment of Healthcare Providers and Systems have added to the environmental complexity and provide further challenges for leadership.2,3 Nurse managers provide leadership for staff at the point of care, but increasingly this responsibility is transferred to charge nurses.
When present, charge nurses are positioned to provide leadership and support for clinical decision making at the unit level on a designated shift.4,5 Page supports a reduction in errors by providing backup support at the unit level to eliminate or assist with recovery from mistakes.6 Charge nurses are suggested as an alternative in providing this support as well as building in redundancy or a system of double checks to increase safety. Despite the implied significance and common acceptance of this role, charge nurses have been both understudied and underprepared.7,8 Charge nurses often perform without a job description or formalized competencies. Little is known about the type of preparation they require, the scope of the role, the kinds of ongoing support they need or receive, and their impact on staff retention, patient safety, and clinical outcomes.
In the literature, there have been no studies about the experience of being a charge nurse from the perspective of those in the role. The charge nurse point of view could provide key insights as healthcare teams struggle to redesign systems to reach the pivotal IOM goals for improvement in the delivery of safe quality care.9 If the charge nurse role is truly crucial in making progress toward meeting these goals, it must be preserved, strengthened, validated, and supported.
The majority of nursing literature published about the charge nurse role dating back to the 1970s is not grounded in research and focuses on role preparation. Sherman and Eggenberger10 discussed the role responsibilities of the charge nurse and the need to develop skills in communication, conflict resolution, and team building. Connelly et al8 conducted one of the few research studies on the charge nurse role, in which 54 charge nurse competencies were identified from interview questions based on Katz’s11 categories of management skills. Most publications have focused on competency development for the charge nurse role. Insight into the role from a charge nurse perspective has been notably absent in the literature. This study increases understanding of the experience of being a charge nurse in the acute-care environment from the perspective of the charge nurse.
Research Methods and Analysis
A qualitative descriptive design was used to explore the experience of being a charge nurse in acute care. Additionally, hospital documents provided insight into charge nurse role expectations from the perspective of nurse leaders in the organization. Themes emerged describing the dynamic process of charge nurses at the frontline, which offers a guide for nursing leadership at the unit level in acute care. Institutional review board approval was obtained from the university and from participating healthcare agencies.
Sample and Setting
Four acute-care hospitals in Southeast Florida were selected as study sites: 2 for-profit and 2 not-for-profit. Facilities selected to participate in the study had a permanent formal charge nurse or assistant nurse manager position where the charge nurse or assistant nurse manager routinely was not required to take patients in addition to his/her leadership responsibilities. Each facility was asked to provide data regarding individual job descriptions, qualifications, professional development for the role, competencies, and compensation for charge nurses/assistant nurse managers, as well as the care delivery model the facility utilized and their nursing organizational chart.
Charge nurses were defined as RNs holding the title of charge nurse or assistant nurse manager in an acute-care hospital and having shift accountability for the overall performance of their unit. A purposive sample of 20 charge nurses (Table 1) consented to participate in the interviews and completed a demographic survey. Only day-shift charge nurses who worked on medical-surgical or telemetry units were included in the sample. Charge nurses who worked in critical care, the emergency room, or on specialty units were excluded from the study as role expectations of charge nurses typically are different in specialty settings. Units to which the charge nurses were assigned did not have any nurses in support roles such as nurse practitioners, clinical nurse specialists, clinical nurse leaders, or clinical educators.
Data Collection and Analysis
Interviews lasting approximately 1 hour were conducted at the facilities in office settings. In order to determine what the experience of being a charge nurse in acute-care practice is like, participants were asked questions using a semistructured interview guide (see Document, Supplemental Digital Content 1, http://links.lww.com/JONA/A119). Data analysis began after each interview session. Parse’s12 method of data analysis focused the researcher on immersing herself in the data transcriptions, reading and rereading the interviews, and coding the data until themes emerged. MAXQDA software was used to assist with data management and analysis. Initial codes for theme development evolved while reading the transcripts that were in the language of the participants (see Table, Supplemental Digital Content 2, which shows selected MAXQDA codes, http://links.lww.com/JONA/A120). The number of times each code was discussed by each participant was noted. Similar codes were grouped together, and major ideas or subthemes about the phenomenon of being a charge nurse emerged from the codes (Supplemental Digital Content 2, http://links.lww.com/JONA/A120; Table 2). From the subthemes, themes that described the charge nurse experience were identified.
Credibility was established by reviewing the process for data analysis with 1 participant from each of the 4 facilities. Each participant was shown their transcribed coded interview in MAXQDA and the subthemes and themes that emerged from the findings. All 4 participants agreed that they were able to recognize the experience of being a charge nurse in acute care from the data.
Eight themes emerged to describe the experience of being a charge nurse in acute-care practice: creating a safety net, monitoring for quality, showing the way, completing the puzzle, managing the flow, making a difference, putting out fires, and keeping patients happy.
Creating a Safety Net
Safety was introduced into the discussion by 12 participants before they were asked how their role impacted patient safety. Charge nurses in this study wanted to create an environment that fosters safety for both patients and nurses. Being the “eyes,” “different eyes,” or “another set of eyes” was a descriptor put forward 5 times in relation to providing another perspective leading to safety. One charge nurse stated, “I think it’s very important… we’re… the safety net. When I go in a room… I look at it from different eyes because I’m not the primary nurse who has already… been given a report. I… go in with a fresh view.”
According to these participants, the charge nurse frequently picks up on something that has been missed by more than 1 primary nurse. Participants saw charge nurses as buffers who catch things that are not as obvious and have potential for falling through the cracks, which may result in errors: “You’d be surprised… the things that you can identify and… nip in the bud.” Frequently, it was the charge nurse who stepped forward and spoke up if there was a break in policy or a risk that could jeopardize safety.
Monitoring for Quality
Charge nurses described needing to have vigilance in monitoring patients, nurses, and interactions between nurses and patients. Rounding and watching over the care process allowed them to oversee and verify that patients were getting what they needed and deserved from the nurses and the healthcare system. One charge nurse stated, “If you are charge nurse, you are monitoring care, making sure everybody follows policy and the patient safety rules and that there is quality of care.” Participants felt this surveillance allowed for early identification of signs of patient or nurse distress. Charge nurses described checking all of the regulatory core measures to ensure completion and that all essential information was documented.
Showing the Way
Charge nurses state they “lead by example” and “earn trust by meaning what they say.” They describe being with, listening, and remaining accessible as important concepts for leading the team. Charge nurses frequently guide staff nurses through communicating with physicians to obtain desired outcomes. One charge nurse commented that when a staff nurse asked, “Should I call the doctor?” she wanted the staff nurse to tell her, “What are the concerns you have?” “Give me the story about the patient.”
Several charge nurses described making decisions about “when to call a doctor, when to address the supervisor,” or when to call a rapid response. An additional comment was: “I have to make sure that I stay up to date on what’s going on in the unit… it’s given me a really broad view of nursing that I didn’t have before as a staff nurse.”
Completing the Puzzle
Participants used terms such as “hub of the wheel,” “facilitator of knowledge,” “all knowing,” and “we’re the glue” in reference to their role in weaving together interprofessional exchanges. One charge nurse expressed this as “pulling everybody together.” They saw themselves as facilitating collaborative exchanges between physicians and other disciplines that were necessary to transition patients to the next level of care. One charge nurse commented, “We’re the people who help everyone stay on the same page. We want everybody to be informed. We want the doctors, the nurses, and the patients, all to be… communicating.” Charge nurses identified the need to be assertive, while not being confrontational, when engaging in interprofessional relationships. These charge nurses desired to develop conflict resolution skills in response to some of the challenges they faced with fostering these connections.
Managing the Flow
There was an inner struggle being in between the nurses and the organization while attempting to foster an environment supporting human caring. Participants wanted to do what they could to provide staff nurses with time needed to care for their patients. The goal for managing flow was to create a balance in the fast-paced stressful unit environment. One charge nurse noted “My challenge is when I have ER calling me, wanting beds, and my nurses have so many patients. They’re busy; we’re getting patients from direct admit; we’re getting patients from the OR, and… it’s difficult… to keep the pace.” The turnover in patient volumes was frequently acknowledged. Participants did not want to keep the patients waiting too long. Yet, they felt obligated to try and control the pace for the nurses, so that it was manageable and not overwhelming. Several charge nurses reflected that at times the nurses would push back if they felt that they were being given more than they could handle.
However, charge nurses saw their responsibilities for patient flow as impacting the hospital on a larger scale. Statements were made about the need for understanding the financial implications of patient flow. At times, the numbers supported the volume of patients, but charge nurses had safety concerns. One charge nurse stated, “the grid says if you have 5 nurses, you must have this many patients. But they don’t see what’s going on, on the floor. They don’t see the safety aspect of it…. You learn that you have to take care of the floor, the patients and the nurses.” Additionally, she said that “as a… leader… you… look… at financials. You have to. You have to say, you know what, at 3:00 o’clock, I got to send a nurse home.” When participants were trying to prevent delays in patient care, provide for patient safety, and comply with staffing grids, they were often caught in the predicament of being pulled in 2 directions at once.
Making a Difference
Charge nurses expressed the benefits of their role as being able to still participate in patient care, maintaining their skills, while making a difference on a bigger level. A charge nurse declared that she was “the glue.” Another felt that if you “have a good charge nurse, you have everything.” “Having a seasoned nurse who holds the unit mission close” was seen “as being invaluable.”
Participants communicated about the need to quantify the impact of their role. They wanted everyone to understand and appreciate what it is like to walk in the charge nurse shoes. “Unless you’re in that position, you… don’t have a good grasp on it… that’s why we’re always saying ‘I think all management should spend 1 day shadowing the charge nurse.’” These charge nurses thought their colleagues often failed to recognize their value. One charge nurse described a previous place of employment briefly getting rid of the charge nurses and then needing to bring them back to manage the volume of orders and phone calls.
Putting Out Fires
Charge nurses in this study saw themselves as the frontline go-to persons smoothing out problems and putting out fires before they started. Three participants described themselves as the “go-to person.” Three different people also referenced their role in “putting out fires.” At least 1 participant said she “wears a fireman’s hat” in her day-to-day duties. As a charge nurse, participants shared they were the “frontline person” of the “command unit.” They also described themselves as “captain of the ship.” Staff looked to them for guidance, and they interceded when necessary.
Keeping Patients Happy
Participants kept patients and families happy by making themselves available to them. Many charge nurses described doing a great deal of listening when rounding on patients. One charge nurse stated, “I round on my patients. I go to each room. I make sure that they know I’m there for them. I’m available, and if there’s anything they need… they can call me directly.”
The participants saw their role as integral to patient satisfaction scores; as charge nurses, they took the time to sit with a patient when they sensed that a situation might be escalating. They were sensitive to the need to act and responded right away. One charge nurse reported doing “service recovery… I like to think with the rounds it doesn’t happen as often, but there’s usually… some kind of issue. And the nurses know that… at the first glimpse that there might be a remote possibility of… something being wrong, they know I want a heads-up.”
Limitations and Discussion
Based on this study, it seems that, in some settings, charge nurses are providing the day-to-day, minute-by-minute leadership at the unit level. However, there were limitations to this study. The sample was composed of an all-female subgroup of charge nurses working only on the day shift in medical-surgical or telemetry units in 4 acute-care hospitals in 1 geographic area. Additionally, conducting the study at the participants’ work sites may have made the charge nurses less likely to share sensitive data.
Information obtained from the organizational artifacts gathered from the facilities was not always consistent with what was gathered from the interviews. In the interviews, the charge nurses identified that they had a clear understanding of what their job description and competencies should be. Yet charge nurses were performing without formalized role-specific competencies in at least 3 of the hospitals and without a job description in 1 hospital. There is an opportunity for the hospitals to engage the charge nurses in dialogue to increase the effectiveness of these documents by understanding what the role responsibilities of this key position are in their organization.
Requirements for the charge role from the organizational artifacts indicate that a bachelor’s degree in nursing is preferred for the position, yet only 33% (n = 6) of the sample had this degree. This is an important finding in relationship to the IOM1 report, which addressed the educational needs of nurses in the current practice environment and called for increasing the proportion of nurses with a baccalaureate degree to 80% by 2020; not just those in formal leadership roles. In a recent position statement published by the Council on Graduate Education for Administration in Nursing, it is recommended that charge nurses should be prepared at the baccalaureate level because of their authority and position as role models.13 Nurses who pursue their bachelor’s degree typically develop competencies in leadership theory, communication, team building, and conflict resolution.
In these practice settings, charge nurses were provided with little continuing education for their leadership role. This fact is supported by the demographic data. Initially, 35% (n = 7) of the participants identified that they had received formal training for the role. However, upon closer review, participants included “precepting,” “shadowing,” and “orientation” in their definition of formal training. The number of participants who actually received formal training was only 20% (n = 4). More structured orientation programs for charge nurses must be developed, given the scope of responsibilities and the level of leadership necessary to function on the unit. If charge nurses were better supported in growing in their role as team leader, they might be able to be used in a greater capacity to lead their unit team to support the organization’s priority agendas.
One additional finding is that charge nurses are performing many of the components of “missed care.”14 They were at the bedside with patients educating them, doing discharge planning, providing emotional support, and conducting surveillance. The amount of missed care certainly would be higher if these charge nurses were not present. Charge nurses also are in the unique role to be able to organize care differently to ensure that essential care was not missed.
Themes emerged in this study suggesting that charge nurses have an impact on improving healthcare: safety, timeliness, efficiency, effectiveness, equity, and patient-centeredness. This study offers understanding about where charge nurses are filling in the gaps from their perspective. Support roles frequently are analyzed in organizations to determine if they are essential to care models. Future research is needed to provide additional support justifying the need for the charge nurse role since these positions often are considered nonproductive costs and incur further expense for education and development. Charge nurses are supporting frontline care at the point of service and provide a unique leadership perspective that appears to improve quality, safety, and patient satisfaction.
The author thanks Drs Rose Sherman, Marlaine Smith, Kathryn Keller, and Nora Triola for their unwavering support.
© 2012 Lippincott Williams & Wilkins, Inc.