ED visits increased from 93.3 to 110.2 million per annum, while at the same time, the amount of 24-hour EDs decreased 12% and wait times increased 36%, which led to 150% longer wait times for ED patients suffering from heart attacks.1 Because the ED process is complex, most, if not all, EDs use a charge nurse to assist in the safe and efficient delivery of patient care.
Unfortunately, most nurses don't receive much management or leadership training in our basic educational foundations. A literature search turned up surprisingly little about the value of formalized charge nurse training programs, and this author's own experience in consulting with EDs around the country found more than 75% of charge nurses felt unprepared to do their job and didn't even know their job description. Building off the information generated from our review, senior ED leadership created our organization's first-ever standardized ED charge nurse program, which has reaped great benefit within our department and the community.
Experts outline several competencies that indicate successful charge nurses:
* achievement group—getting the job done
* management group—working through others
* interpersonal relationships group—working with others
* problem-solving group—thinking through issues
* personal performance group—managing one's self.2
Another article, by Krugman and Smith, revealed other literature that was thought to be a central part of charge nurse education and training.3 Their literature review showed various areas of education as crucial to charge nurse development:
* leadership theory
* conflict resolution
* stress management.
We started with a basic foundation of the various roles and expectations of a charge nurse. Because our ED already had a core group of permanent charge nurses, we began our training with them. The areas we focused on as important for patient care included:
* patient flow. How can we get the patients into and through our system more efficiently without overwhelming limited resources?
* staffing. With the nursing shortage being discussed throughout the nation, how can we be creative in our use of our most precious but limited resource?
* quality management. We felt the charge nurses needed to have accountability for the quality of care. By obtaining their support in areas such as patient wait times, left without being seen (LWBS) rates, and quality of staff nurses' documentation, we felt the result would encourage more ownership of the process.
* leadership and teamwork. We focused on leadership theory and how the charge nurses could develop their own leadership style that worked with the staff and the organization as a whole.
Our next function was to make sure we could provide the tools and resources for the charge nurses so they could meet our expectations. We defined the expectations with clear, objective goals and then provided the references and resources for the charge nurses to utilize. For example, we provided the charge nurses with the basic understanding of how staffing and volumes merge to create an overarching productivity volume that dictates the ability to replace staff who have left the department, increase our budget, and essentially justify our department's continuing existence. After we gave the foundation of how all those elements worked together, it became easier for the charge nurses to determine when to increase staffing through on-call systems or decrease staffing by sending people home early or calling them in late.
We continued to provide monthly seminars (typically 30 to 60 minutes in length) on various topics, such as conflict resolution, time management, patient satisfaction, staff morale, and budget. Each time the charge nurses received information on a new topic, the management team worked with them on ways to implement some of the ideas or changes so it became part of the routine and expectation, not just another training session. After the charge nurses saw how to turn an idea into reality, implementing the changes became easier and the staff accepted them more readily than before.
We began to track objective data on a variety of process improvements before we implemented our formal training program:
* LWBS rate. Our department goal had always been an LWBS rate of less than 2% but during the last part of 2007 and into early 2008, we noted significant rises. Our highest LWBS rate (7.1%) was right before we formally implemented our training program.
* length of stay (LOS) rate. Our LOS in February 2008 was over 5 hours for patients waiting for admission and about 3.5 hours for patients who were discharged home.
* patient satisfaction. Our Hospital Consumer Assessment of Healthcare Providers and Systems scores were dismally low at 32.7%. To be considered world-class, we needed a 30.4% increase, which seemed monumental at the beginning of this project.
* staff satisfaction. Because the turnover rate under previous management had been so high (48%), staff morale was low. Staff members were tired, overworked, and felt undervalued.
* orientation program. This program was outdated and not well monitored. New staff members were frequently paired with somewhat less new staff, resulting in spotty orientations at best. Before the training program implementation, the turnover rate for new associates was 20% or higher.
After we implemented the training program and began the mentoring sessions, we noted significant improvement:
* The LWBS rate decreased to 1.8% within 2 months.
* The LOS rate for admission dropped 15% and discharges home dropped 13%.
* Patient satisfaction increased by 17% within 1 month of our process improvements.
* As the staff came to realize the charge nurses were there to support them and management was providing the needed tools and equipment for them to provide the best patient care possible, the atmosphere around the department increased significantly. The turnover rate was consistently less than 3.5% and the vacancy rate less than 8% after the charge nurse training program was implemented. Our organization had its annual staff satisfaction survey right around this time and department management and leadership had some of the highest scores in our facility.
* The orientation program received an overhaul by the educator and was more standardized. Each nurse was paired with experienced, trained preceptors instead of being placed with whomever was convenient and available. The orientation program for technicians now included a mentoring program (one of the many bright ideas generated by the frontline technicians), which enhanced their experience. We only lost 1 (8%) of the new hires by the end of the orientation period.
Other benefits included:
* physician satisfaction. The physicians frequently commented on how much better things were going and how much they appreciated the staff utilizing collaborative practice and greeter mode. This also got them on board with goals of 30-minute door-to-provider times and also enhanced overall patient satisfaction.
* Fast Track. Instead of our traditional 4:1 RN-to-patient ratio, our Fast Track area is 5:1 with three rooms designated for Fast Track and the other two for regular ED patients. The result was a much better flow for all our patients; the staff knew where the Fast Track rooms were and our mid-level providers (physician assistants) were no longer getting Fast Track and regular ED patients intermingled.
* staff ownership of the department. Preparing for our upcoming Joint Commission survey was incredibly easy. After guidance was provided to the charge nurses, the staff quickly came on board with checking expiration dates, quizzing each other, and making sure the department would perform at its best.
The charge nurses even revamped the relief charge nurse orientation program. We have several staff members on the waiting list for relief charge nurse training, which has been an unexpected bonus for our hard work, focus, and dedication.