Krugman, Mary PhD, RN, NEA-BC, FAAN; Heggem, Laura BSN, RN, CCRN; Kinney, Lisa Judd BA; Frueh, Margaret MS, RN
Acute care nurse executives place a high premium on expert clinical nurses who assume the role of unit-based charge nurse (CN), for this nurse is responsible for a significant flow of activities to ensure safe, efficient, and seamless care delivery. Charge nurses play a crucial role in the hospital infrastructure, acting as mediators for patient complaints, exercising the critical work of assigning competent nurses to groups of patients, facilitating coordination of safe patient care across the continuum, serving as an interdisciplinary liaison, and managing the churn of the unit as capacity issues arise.1,2 Although the role varies nationally and internationally, CN leaders impact patient and nurse satisfaction ratings, risk management and safety issues, physician relations, and the patient discharge process, all critical hospital metrics. This publication will report on the outcomes of a 16-year CN program, describing changes since 1st reported in 2003,3 how these changes influenced the current CN role at this Western academic hospital, and implications for nursing leadership.
Review of Literature
Literature through the decades reports struggles clinical nurses experience when assuming CN roles. Not all clinical nurses can meet the rigorous role expectations, with questions raised as to whether the nurse is a poor fit or lacks adequate preparation for leader responsibilities. Early literature described role functions, competencies, issues related to delegation, problems due to inexperience, and development programs. Recent literature describes research conducted nationally and internationally, a positive advancement for the field. Admi and Moshe-Eilon4 developed and tested the Charge Nurse Stress Questionnaire, reporting Israeli CNs experienced low to moderate stress; areas of highest stress were managerial-type decision making, conflicts, and lack of resources. This instrument warrants validation by United States–conducted research. Duygula and Kublay5 used Kouzes and Posner’s6 The Leadership Practices Inventory (LPI) to measure CN leadership skills following a structured program, comparing their self-reported leadership abilities to observer ratings of the CNs on clinical units. Results reported similar findings as Krugman and Smith,3 where CNs held higher self-rated leadership skills than did comparison groups. Kalisch et al7 recognized a gap in CN teamwork. Using an author-developed conceptual framework, a qualitative study was conducted using focus group methods. Results uncovered the challenges clinical nurses experience when per-diem CNs change shifts frequently; clinical nurses had to constantly adjust to different leadership styles. A qualitative study conducted by Patrician et al8 determined CNs face 4 major challenges: managing staff performance, role clarity, powerlessness with complex systems, and lack of leader support.
In 1996, the University of Colorado Hospital (UCH) executive team reorganized the administrative structure across hospital departments to reduce complexity. The reporting structure changed, with frontline employees reporting to a supervisor who was accountable to a vice president. As a result, some nurse manager positions were eliminated, whereas others were converted to a nursing director role. This change significantly increased the director span of control to overseeing multiple units. The restructuring created a gap in the consistency of day-to-day leadership; thus, in response, nurse executives developed and implemented a permanent CN role. An evaluation research study was initiated to measure the effects of these structural changes using action research9 as one of the underlying study frameworks; nursing leadership desired timely data on the structural change outcomes. Because the healthcare environment is constantly changing, this method of inquiry permitted nurse leaders to review rapid cycle data to facilitate executive decision making. Nurse leaders also selected a leadership framework to measure leadership practices of permanent CNs, Kouzes and Posner’s10 The Leadership Challenge, and their instrument, the LPI.6 Since the original report of these research outcomes in 2003,3 hospital organizational structures and the CN leadership program have continued to undergo changes.
1. Is there a difference in CN self-reported leadership practice ratings across timed data periods after restructuring supervisory roles and changes in educational interventions?
2. Is there a difference between permanent CN LPI leadership ratings compared with clinical nurse ratings of their leadership and compared with relief CN LPI ratings?
3. Did planned action research interventions by nurse leadership result in measureable outcomes aligned with leadership goals?
4. Are differences reported in CN demographics from 1996 to 2012?
This institutional review board–approved study used action research9 and Kouzes and Posner’s10 The Leadership Challenge as conceptual frameworks for the study because both captured specific and essential study dimensions. Lewin’s9 work, modified by Dick11 and O’Brien,12 served as the basis for examining how organizational change can be measured in ways that capture the cyclic dynamics of trials to implement improvements. Kouzes and Posner’s10 work on leadership concepts related well to the leader practices of the CN role. The 5 domains, encouraging the heart, enabling others to act, inspiring a shared vision, challenging the process, and modeling the way, incorporate concepts that are embedded directly in the instrument for measurement.10 At the time this research was initiated in 1996, there were few published conceptual frameworks that included a highly reliable instrument aligned with the theoretical concepts of leadership.
The primary instrument, Kouzes and Posner’s6 LPI, is highly reliable with an α coefficient = .96 and strong content validity. It has been tested on subjects in both the United States and internationally and is readily available by request to the authors. The 1996 permanent CN baseline α coefficient was .92. This reliability value remained consistently strong across research phases. The 30-item LPI is formatted with a 5-point scale ranging from 30 to 150; the higher the scores, the stronger the self-perceived leadership skills. Kouzes and Posner6 modified the instrument over time. To maintain consistency of longitudinal comparisons, UCH continued to use the original instrument. Survey measures associated with the action research component of the study were developed to provide data on specific interventions decided by nursing leadership at various study phases. Examples include a team-generated needs assessment, a role inventory checklist, and a survey of permanent CN ratings of their leadership program.
The LPI used convenience samples of permanent CNs, clinical nurses, and relief CNs (Table 1) who voluntarily responded to an invitation letter to participate in a study of self-reported CN leadership practices. Respondents in this longitudinal survey were not matched by unit or tracked by deidentified codes across the study time periods because of a decision by nursing leadership to collect only aggregate data. There was a strong belief the response rate would be very low if nurses perceived they would be tracked by code or unit. This decision to collect only aggregate data was reaffirmed over time. Leader input on this decision is consistent with the collaborative, participatory model of action research. Some smaller units also had very few permanent CNs so coding subjects could have potentially compromised protection of human subjects. Participants in the action research components of the study were voluntary subjects who responded anonymously; data were aggregated since each action intervention differed by time period and change initiative.
This study was conducted in 3 phases. In Table 1, each phase is outlined to provide a summary of the time period, sample size, and statistical outcomes. There were significant discussion and reflection by nursing leadership at each point in the 3 phases. Therefore, narrative text is included to capture the action research component of this evaluation study.
Descriptive statistical procedures profiled respondent demographics and described study variables. Comparisons using t tests and analysis of variance (ANOVA) procedures were conducted to examine differences among and between subject groups. Cohort groups were not coded, nor were respondents matched per the collaborative decision with nursing leadership, so standard statistical procedures were utilized.
Phase 1: 1996 to 2000
In phase 1, a number of action interventions were conducted to redesign certain institutional processes, including initiation of the permanent CN role.3 Nurse executives in 1996 made the decision to evaluate permanent CN role functioning using 2 methods: the UCH performance appraisal for institutional standards evaluation and the LPI survey to gain data on permanent CN perceptions of their leadership in this new role. A collaborative decision was also made to measure how the unit clinical nurses perceived the CNs’ leadership practices, an important comparison for how CNs were able to fill the leadership gap without nurse managers. Over the 5-year period, the aggregate sample was composed of 258 of 373 permanent CNs (response rate, 69%) and 1,004 of 3,579 clinical nurse subjects (response rate, 28%) who completed the LPI from 22 inpatient units. When a trend was detected after the 1st 2-timed measurement periods, that clinical nurses rated permanent CN leadership practices lower than did the charges, 3 action research interventions were initiated with the goal to close that gap. The 1st 2 interventions focused on creating 2 additional leadership courses: one on coaching employees toward improved performance and the other on financial management. The 3rd intervention, establishing a CN leadership council led by permanent CN cochairs, provided an important structural empowerment forum to share information and address system issues to improve role effectiveness and was integrated into the transformational leadership dimension of our shared leadership model.
A final action research intervention during phase 1 was to survey the permanent CNs to determine their overall views of the educational interventions activated during phase 1: Did they perceive the leadership program strengthened their abilities to lead? Twenty of the 68 permanent CNs (31%) responded to questions about the required human resources (HR) leadership courses. The majority of respondents rated the courses as somewhat helpful but included feedback that leadership concepts were difficult to incorporate into practice. Several respondents perceived direct coaching was needed to improve leadership skills. Human resources courses proved a source of dissatisfaction for many respondents, because the courses included many different types of employee positions; CNs did not feel the discussions and scenarios related to their role.
Data analysis over the 4 time periods reported LPI permanent CN mean scores significantly improved by 2000 (Table 1). Although clinical nurse views of permanent CN leadership improved, there continued to be a gap between the 2 comparison groups. Clinical nurses reported CNs declined in 3 domains: encouraging the heart, enabling others to act, and modeling the way. Permanent CNs’ self-ratings, however, improved in 3 of 5 LPI domains (Table 1). Demographic data reported remarkable stability from 1996 to 2000. Greater than 50% of the permanent CN cohort group had practiced more than 15 years, and greater than 60% remained in the CN role at UCH over the 5-year study period. The majority of permanent CNs were 36 to 45 years, with low turnover and high satisfaction as members of the UCH UEXCEL Professional Practice Program (PPP).
Phase 2: 2001 to 2007
Although permanent CNs gained excellent skills in managing the daily flow and function of their units, they experienced difficulty acting in the role of episodic manager when the director was not available, particularly in areas of coaching staff and supervision. Nursing leadership reviewed phase 1 data, recognizing the demands of unit leadership in a complex academic hospital exceeded the job description of a permanent CN. Directors expressed frustration trying to meet frontline CN and clinical staff needs without unit managers. There was mutual agreement by all leaders, including strong advocacy by the chief nursing officer (CNO), to reinstate the nurse manager position. Using Bridges’13 Managing Transitions as a framework, units transitioned back to the manager model. The transition required significant attention to role differentiation, because the manager position had been absent for 5 years, and many permanent CNs expressed uncertainty about the changes and lack of role clarity.14 An action research intervention was initiated after the new teams were established, to evaluate the role transition using an internally developed role function survey. The executive team, with participation by CNs, developed a survey formatted as a simple checklist for each group to identify what activities belonged to the respective positions, along with several open-ended questions. Results reported clear consensus on items specifically tied to job descriptions, such as agreement that nurse managers controlled the unit budget and CNs were responsible for daily assignments. Items such as hiring employees and conducting performance appraisals reported mixed results. Open-ended responses provided further insights on manager/CN viewpoints. Outcomes were reviewed with leadership followed by small group unit meetings. Charge nurse and manager performance expectations were finalized; permanent CN leadership standards were updated in the UEXCEL PPP (see Table, Supplemental Digital Content 1, http://links.lww.com/JONA/A241) and available as resource material.
The nurse executive team recognized that changes needed to be initiated in the permanent CN leadership program. However, plans for major program revisions were postponed because of institutional changes, a situation that also impacted the LPI permanent CN leadership survey data collection. The hospital began preparations to move to a new facility located 6 miles away. Intensive organizational realignments were underway for several years, resulting in significant structural leadership changes. Units were reconfigured to match the new hospital footprint, with some nurse managers and permanent CNs reassigned to newly formed or different specialty units. Conducting the LPI survey was not feasible because of these significant changes.
Attention during this period focused on the selection, orientation, and development of relief (per diem) CNs, an important focus because this role is the traditional pathway to a permanent charge position. Poor preparation as a relief CN translates to inadequate performance in the permanent charge role. A team composed of diverse stakeholders was convened to address gaps in relief CN role preparation. Until this initiative, relief CNs were oriented by unit, a process characterized by lack of consistency and structure. The 1st action research intervention focused on developing and conducting a needs assessment to determine current practices and solicit suggested content for a new centralized relief charge leadership program. Survey results guided the team to develop a leadership orientation program similar to Flynn et al14 and construct a scope of practice. It was important to define the scope of the relief CN role, because unlike the permanent CNs they remain in their current clinical nurse position and receive a differential per shift rather than a promotion. Scenarios were created to facilitate small group discussions on best practices for managing difficult situations. Permanent CN leaders assisted with course coordination and instruction. Kouzes and Posner’s6 LPI was initiated to measure relief CN self-reported leadership ratings prior to the program and at 6 months after the course. The relief charge leadership course and precepted clinical orientation reported successful outcomes, with an overall average course rating of 3.52 on a 4-point scale, and positive feedback on open-ended evaluation questions. During this time period, voluntary relief CN subjects were invited and enrolled into the study with phases of groups corresponding to their course registration. Relief CN respondent demographics reported the majority worked at UCH for 3 to 5 years and had served in the role of relief charge less than 20 times in the 6-month postcourse period. The median length of employment at UCH prior to taking the course was 2.87 years. In phase 2, it was anticipated the participants in the precourse group would rate their leadership skills lower before than after the course. The actual outcomes reported the precourse group’s LPI scored higher than did the postcourse group, suggesting that when the reality of the role became apparent through practice, relief CNs modified their post-LPI ratings. There were no significant differences in the domain scores between the 2 groups. In phase 3, between 2008 and 2010, only 4 of the LPI items were rated differently between pre- and post-LPI testing. One domain was significant, “enabling others to act.” Outcomes can be reviewed in Table 1.
Phase 3: 2008 to 2012
This 4-year period represents the final data collection of both permanent and relief CN leadership practices. Survey results in 2008 reported no differences in permanent CN LPI mean scores when compared with the 2000 survey. Although this was encouraging because there had been so many significant institutional changes in the previous 8 years, the flat ratings raised questions about the impact of the educational interventions. The leadership program had continued throughout the time period with a new HR instructional team and minor programmatic changes. Interviews with CNs and managers led to the realization that required courses were often not completed in a timely way or were indefinitely incomplete. Barriers were uncovered, such as infrequent HR course offerings and last-minute course cancellations. Human resources and nursing leaders convened a team that included permanent CNs to take action, reviewing the HR leadership materials and course ratings. The result was a revised leadership program designed with collaborative stakeholder input. Courses deemed mandatory for competency were separated from courses identified as enhanced enrichment. Schedules were changed to include courses as part of the regular CN leadership council meeting or on that same CN day. This day offers protected time to facilitate permanent CN meetings with nurse managers as a team to discuss unit issues and performance management plans and to review unit quality metrics. Streamlining the courses to align with this day resulted in improved attendance, reduced administrative costs, and enhanced structural empowerment. The revised course program can be reviewed in Table 2.
A 2nd significant change between 2008 and 2012 was the introduction of hospital critical quality metrics into employee performance appraisals at all levels, including management. This change introduced rigor into unit leadership with renewed coaching and strong partnerships between managers and permanent CNs in order for units to meet the expected benchmarks. The revised leadership curriculum and increased partnership activity contributed to improved permanent CN LPI scores in 2012, although not at a statistically significant level. Further analyses were conducted comparing the 2012 results to all time periods; significant differences were reported. Post hoc tests comparing the time periods using ANOVA and t test procedures reported 2 domains, “enabling others to act” and “inspiring a shared vision,” significantly improved (Table 1).
Demographic data documented significant changes in the permanent CNs over time. In the 1996 to 2000 data period, CNs were older and very experienced with greater than 50% having practiced for more than 15 years. Between 2001 and 2008, the group demographics began to change, with CNs’ age and practice longevity distributed across ranges. In 2012, permanent CNs were reported as a significantly younger cohort group, with 48% in the 25- to 35-year age range and 53% between 2½ and 5 years of experience. These data reflected the demographic changes in our nursing workforce, because more than 50% of our inpatient clinical nurses are younger and newer to practice as former residents of our University HealthSystem Consortium/American Association of Colleges of Nursing National Post Baccalaureate Nurse Residency Program.15
Permanent CNs were also asked an additional set of questions in the 2012 data collection to evaluate the revised leadership curriculum. Of the 82 respondents, 76.8% had participated in the new leadership development program. Fifty-one (78.4%) agreed or strongly agreed the program prepared them for supervising, evaluating, and disciplining staff, whereas 47 (73.4%) agreed or strongly agreed the program prepared them to lead day-to-day patient care unit issues. Most respondents (55%) had not taken the previous HR courses, but of those who took the older courses, 25% thought the program had improved, whereas 20% reported it was similar. There was wide variation in qualitative responses. Several respondents requested courses be taught by managers and directors rather than HR personnel; 1 CN suggested managers shadow them to provide more direct leadership coaching. Nursing leadership is considering further action interventions related to these qualitative suggestions.
Relief charge LPI final data administration surveyed those who had taken the structured nurse orientation leadership program between 2006 and 2012 to examine longitudinal differences in self-reported leadership practices. Results of testing between the 2006 and 2010 relief CNs as compared with the aggregate 2012 respondents using t test procedures reported significantly higher 2012 scores with equal variances assumed (Table 1). Although the 5 LPI domains reported improved mean scores, only 1, “inspiring a shared vision,” was statistically significant. By 2012, a positive finding was that relief charges reached the same level of self-rated LPI practices as the permanent CN group without any specific ongoing leadership program beyond the 1-time daylong leadership program. The aggregate mean score comparisons and domain scores showed no significant differences (Table 1). Another relief CN finding was the improved mean scores of action-oriented items: seeking out challenging opportunities, involving others in action planning, looking ahead and forecasting, and asking others how to do things differently if not done well.
2012 Comparison of Permanent and Relief CN Demographics
Respondents in both groups were female (88%) and white (87%) and reflected an age distribution of 25 to 35 years to older than 55 years. The majority of subjects, 62%, represented the younger 25- to 35-year age group; 36.8% of the relief charges and 15.9% of the permanent CNs worked 3 to 5 years, whereas 35.4% of the permanent charges and 16.1% of relief CNs worked for more than 15 years. The majority of both CN groups (87.2%) held BSN degrees. Among the 83 permanent CN respondents, 43.4% had graduated from the University HealthSystem Consortium/American Association of Colleges of Nursing Post Baccalaureate Nurse Residency Program,15 whereas 62.1% of relief charges were residency program graduates. These data illustrate the career development of our former graduate nurse residents, reflecting the residency program’s success in retention. Relief CNs were also asked questions specific to their role. Frequency of work as a relief charge ranged from once every 6 months (8%) to twice or more a month (62.1%). Seventy-seven percent of respondents affirmed the program had been very useful. Data also reported that 85% of the 142 relief CN respondents were actively involved in committees and unit improvement projects and as a preceptor. This engagement is a strong indicator of how a structured and well-supported relief charge program can result in expanded leadership beyond the episodic charge role, contributing to a positive work environment and increased professional commitment.
Many internal and external forces have acted on the CN role over the past 16 years, shaping strategies for leadership development based on evaluation outcomes. Despite significant structural and organizational changes, the CN leadership scores on Kouzes and Posner’s6 LPI instrument have not dipped less than 65% and now report a 76% rating. Relief CNs gained in self-reported leadership practices, matching the permanent CN self-ratings in 2012, despite being a cohort group with significantly less practice years and not having an ongoing structured leadership program beyond the initial 1-day program. University of Colorado Hospital CN leaders hold attributes of resilience16 with flexibility and positive responses to change, significant work enjoyment, and competence as leaders of the interprofessional team. A structural empowerment pillar that supports this resilience and commitment is the UEXCEL PPP, in place for 22 years. The pathway to becoming a relief or permanent CN results in professional recognition and fiscal rewards, increased retention, and a stable process for succession planning. An analysis of the UCH nurse manager and director leadership team reported that 53% had advanced in UEXCEL, the UCH PPP prior to becoming nurse leaders, and 62% had been CNs prior to promotion. The UCH PPP is a key structure to empower our permanent CNs, contributing to UCH receiving Magnet® hospital recognition 3 times. A 2nd significant structure for the development of strong relief and CN leadership programs is the Commission on Collegiate Nursing Education–accredited nurse residency program. This program has transformed our workforce and the CN leadership program by generating a large pool of exceptionally qualified graduate nurses who are well educated, confident, and eager to move forward in their careers through leadership roles.
The 16 years of developing and evaluating CNs have generated a number of lessons. Both the action research interventions and results from the LPI survey document that leadership courses alone do not develop a CN leader. Unless development initiatives are linked to mentoring and coaching, it is difficult for frontline clinical nurse leaders to integrate the concepts into practice. Leadership courses should be carefully tailored to CN needs to ensure utility of sessions. Another lesson learned is the need for oversight of a CN leadership program. Without a structure to track program interventions, data outcomes cannot be directly correlated to the impact of changes linked to hospital quality metrics, an important future consideration as the healthcare environment continues to rapidly change.
This longitudinal research studied CN groups that changed over time; respondents in 1 time period may or may not have participated in previous LPI surveys. The action research interventions reported goal-driven outcomes, but the participatory, collaborative nature of this type research could not be statistically correlated with LPI outcomes or to other hospital metrics. The decision not to code CN respondents limited the types of statistical procedures used in this study.
Developing and evaluating permanent and relief CNs longitudinally have yielded insights into how to manage human capital to create talented and flexible frontline nurse leaders. Structures that empower clinical nurses to transform their work environment through the growth and development of leadership abilities contribute to a professional culture reinforcing the characteristics of a Magnet-designated hospital. Charge nurse leadership development cannot take place without purposeful mentoring and coaching by nurse managers and directors, led and modeled by the CNO. Charge nurses are a critical link to creating an optimal environment for patients, families, and teams. Their development and leadership preparation should now move beyond the traditional curriculum toward innovative learning that matches a rapidly changing healthcare environment. Charge nurses must be prepared as partners to be leaders in an uncertain future that forecasts exciting transformations in healthcare delivery.
The authors thank Carolyn Sanders, PhD, RN, NEA-BC, CNO and Vice President, Patient Services, and past CNO and Vice President Colleen Goode, PhD, RN, NEA-BC, FAAN, for their support of this research. The authors also thank the permanent and relief CNs who have shown extraordinary frontline leadership over the past 16 years as participants of this study.