The charge nurse role is one of the most important roles in the organization but receives limited time for training or orientation.1,2 Charge nurses are an extension of the leadership team. Leadership is an inherent part of their evolving role and responsibility. Although limited research exists about charge nurse training, innovative and effective opportunities to successfully prepare and retain charge nurses are needed. Without training, a gap is created that makes it difficult for charge nurses to adapt and fulfill their roles. To develop and sustain a healthy work environment, promote effectiveness in the role and to support clinical nurses, it is imperative to provide training opportunities for charge nurses. Thus, a new pilot training program was developed to foster leadership skills and nurture resiliency.
Charge nurses are expected to perform a multitude of tasks while serving as important unit leaders. According to Clark and Yoder-Wise,3 the role of the charge nurse is to ensure duties are accomplished, issues are resolved, and patients are appropriately cared for. Delamater and Hall4 sought to evaluate congruence among findings from 9 studies on charge nurse development. Among the leadership skills that were identified as being important to the role, communication was the most consistently reported area in which charge nurses needed to demonstrate effectiveness. Managing teams was 2nd on the list of reported skills. Other skills identified included conflict resolution, delegation, and the ability to support healthy work environments and service excellence. Charge nurses directly impact patient and employee satisfaction, unit costs, and patient safety. In addition, their support can reduce employee stress and illness-related time off from work and improve patient outcomes.5,6 Although charge nurses play such a critical role, they are rarely provided the necessary training and orientation when transitioning from the staff role to their new position.7 A review of the charge nurse role found uncertainty around nurse leader expectations and poorly defined leadership standards.8 Gaps in expectations and standards can lead to a lack of clarity regarding one's responsibilities and create confusion among the team.
To address this issue, we engaged in charge nurse training; however, research is limited. Stoddart et al8 reported positive perceptions of clinical leadership, clinical team performance, and improved care delivery after formalized charge nurse training. Another study by Clark and Yoder-Wise3 found that charge nurses who participated in simulation training better understood the intricacies of their position and were more adequately prepared to address stressful and emergent situations. In addition, undergoing a leadership training program clarified expectations, increased confidence, and provided the necessary tools for successful clinical leadership.8 Although these studies reflect positive outcomes, more research is needed to further understand the impact on charge nurses who undergo training.
The study objective was to investigate a charge nurse training pilot program as an effective, evidence-based training modality to improve leadership style and resiliency. Outcomes were measured at baseline and posttraining in 2 distinct areas: leadership style and resiliency. Secondary objectives included examining the differences between an intervention and a control group. The pilot program was designed to support orientation for new charge nurses as well as a professional development opportunity for charge nurses currently in the role.
The recruitment pool was approximately 300 charge nurses working in an 11-hospital integrated nonprofit healthcare system located in a southeastern state. Study approval was obtained by the university institutional review board to ensure the protection of human subjects. Before this pilot study, no formal charge nurse training program was available for charge nurses within the system. To meet study inclusion criteria, charge nurses must have met the definition of a charge nurse, be willing to complete surveys and training, and have achieved a performance evaluation that met expectations with no ongoing performance improvement plan. A charge nurse was defined as a registered nurse who was responsible for directing and overseeing the daily activities of the unit on an assigned shift to assure successful safe delivery of care. Charge nurses volunteered and were randomly assigned to either an intervention or a control group based on hospital. This ensured all hospitals were represented.
A demographic questionnaire, the Multifactor Leadership Questionnaire (MLQ-5XShort),9-11 the Connor-Davidson Resilience Scale 25 (CD-RISC-25),12 and a 14-item course evaluation comprised the surveys. Sample data elements in the 15-item demographic survey included age, gender, and tenure as a charge nurse. A course evaluation using a 5-point scale and 3 open-ended questions was completed only by the intervention group.
Multifactor Leadership Questionnaire
The 45-item MLQ-5XShort questionnaire measures leadership style (transformational, transactional, passive avoidant, and leadership outcomes) and 5 attributes of transformational leadership (idealized attributes and behaviors, inspirational motivation, intellectual stimulation, and individual consideration).9-11 Items are rated on a 5-point Likert scale (0 = not at all and 4 = frequently, if not always). Scale and subscale mean scores range from 0 to 4. Extensive psychometric testing has been conducted on this survey.9-11
Connor-Davidson Resilience Scale 25
The 25-item scale measures resiliency attributes including personal competence, trust in own intuition, acceptance of change, control, and spiritual influences.12 Items are rated on a 5-point Likert scale (0 = not at all true and 4 = true nearly all the time). Total scores range from 0 to 100, with higher scores reflecting greater resilience. Psychometric testing has been conducted on this survey.12
In 2018, the chief nurse executive of the health system and the chief nursing officer (CNO) council decided it was essential to clearly define the role of the charge nurse as a permanent leadership position within the organization rather than a function that experienced nurses performed on a rotating basis. This decision required a specific job description, compensation analysis, job posting, and targeted internal recruitment. Although the organization has nurses who have been trained to perform “relief charge” duties, meaning that they are not in a permanent charge nurse position, most units are staffed with nurses who are exclusively designated as a charge nurse.
The organization partnered with Catalyst Learning to execute NCharge (Table 1), an evidence-based curriculum using a classroom-based, instructor-led training model. Two employees received training via WebEx from the vendor (8-hour online interactive training) to provide the training content to the charge nurses. More than 70% of the course curriculum was spent in group discussions and interactive learning activities. The class was scheduled in December 2018 (8.5-hour course including 7 continuing education hours) at the health system's learning center and provided by the employee trainers. Class courses included supervisory skills for positive outcomes and critical thinking for charge nurses. The supervisory skills course was chosen because of its focus on communication styles, managing conflict, and accountability for healthcare outcomes. The critical thinking course was chosen because managing complex decisions is part of the role as charge nurses are responsible for acuity-based staffing and managing assignments. Course objectives and American Organization for Nursing Leadership Nurse Manager Competencies/NCharge Competencies Cross Walk are presented in Table 1.
Resiliency and Wellness
During the last few years, the organization persevered through significant changes, doubling in size to integrating to 1 single electronic medical record. Nurses and leaders were fatigued from these demands and pressures; thus, the organization collaborated with a consulting firm specializing in organizational culture, building healthy effective teams, and developing highly capable leaders. Together, we designed a resiliency-based development program for nurse leaders. Part of the organization's overall personal leadership model begins with a deep self-awareness journey toward building and sustaining a strong foundation of personal resiliency. This approach supports individuals as they build a new overall life strategy and mindset toward personal wellness. This strategy includes very specific rituals that allow individuals to rejuvenate their physical energy, emotional state, mental alertness, and inner spirit. Executive nursing leadership attended 4-day resiliency sessions that included directors and executive directors. This extended workshop helped to build a foundation for leaders to set the example for wellness and resiliency to all levels but particularly to the cadre of charge nurses. The charge nurses attended a specifically designed 8-hour, 1-day, in-person session on February 8, 2019. The workshop focused on building a foundation for self-awareness and rejuvenation, understanding factors that lead to burnout, exploration of various life components, and strategies to create equilibrium and wellness.
Resiliency training plays a positive role in managing stress.13 Individuals who show traits of resiliency also demonstrate characteristics of a sense of self, determination, a prosocial attitude, and the ability to rebound. Leaders can help improve resilience in nurses by fostering teamwork and facilitating support from management and peers.14 Resilience allows an individual to cope with stress by recovering or adjusting better after a stressful situation. Positive and supportive relationships at the workplace can help with resilience.15-17 Resilience is a dynamic and important characteristic in the current work environment.
Data Collection Procedures
Data collection occurred from December 2018 to February 2019. Hospital CNOs and directors of nursing provided study investigators a list of charge nurses who were interested in participating in the study. Participants were contacted and provided with study information on a 1-on-1 basis by the primary study investigator or 1 other identified co–primary investigator via email and telephone. The assessments were accessible by clicking on a secure intranet web link directing participants to complete the various questionnaires for both groups. A priori power analysis was conducted using an α = .05 significance level, a moderate effect size (f2 = 0.5), and a power of 0.95, and 47 charge nurses were needed for the sample.
Data Analysis Plan
Quantitative data were analyzed with descriptive and inferential statistics Statistical Package for the Social Science, version 25.0 software (SPSS Inc, Chicago, Illinois). Preanalysis data screening was conducted before statistical analysis. Data were analyzed as a group, then separately, to identify any differences or similarities. Descriptive statistics, including frequencies, percentages, medians, means, and standard deviations, were determined and reported on for demographic variables and leadership surveys. χ2 Tests were used to compare the sample demographics. Wilcoxon rank sum test was conducted to determine the effects between the independent variables secondary to nonnormally distributed data. A P value of less than .05 was considered statistically significant. Three charge nurse question responses were loaded into MAXQDA Plus 12.0 (VERBI, Berlin, Germany) to sort, manage, and code the data.
Initially, 44 participants (6.8%), randomly and equally split between the control and intervention group by an electronic statistical program, consented to participate. The final sample included 41 participants, 19 from the control and 22 from the intervention group. To check for systemic dropout, participants who discontinued participation, as seen in the control group, were compared with those who completed the study. No statistically significant difference was found in demographic characteristics. Baseline characteristics in the 2 groups were similar except gender (P = .000), race (P = .000), education (P = .000), and specialty board certification (P = .001), which were significantly different between the 2 groups (Table 2). Most participants were white (59%), female (98%), and prepared at the baccalaureate degree level (61%) without having attained a specialty certification (76%). These participant demographics are congruent with the potential sample from across the system.
Leadership and Resiliency Outcomes
Wilcoxon signed-rank test was conducted to evaluate leadership style using MLQ-5XShort and resiliency using CD-RISC-25 outcomes for the entire sample. All scales had a high level of internal consistency as determined by Cronbach's α (Table 3). There was a statistically significant median increase in transformational (median, 3.35-3.80) (z = −4.60, P = .000), transactional (median, 2.38-2.50) (z = −2.39, P = .02), and leadership (median, 3.33-3.78) (z = −4.04, P = .000) outcomes from preintervention to postintervention for the entire sample (N = 41). Similarly, there was a statistically significant median increase in resiliency scores (median, 89) from preintervention to postintervention (median, 94) (z = −3.75, P = .000) for the entire sample (N = 41).
Findings indicated that most charge nurses' leadership styles aligned with that of transformational (z = −3.59, P = .000), followed by transactional (z = −1.60, P = .109) and passive avoidant (z = −1.12, P = .265) (Table 3). Of the 22 charge nurses recruited to the study, the training elicited higher satisfaction with leadership behavior (mean, 3.88; median, 4.00; z = −2.41, P = .02), followed by effectiveness (mean, 3.68; median, 4.00; z = −2.41, P = .02), and finally their ability to motivate (mean, 3.65; median, 4.00; z = −3.01, P = .003). Charge nurses who attended training had higher resiliency scores, reflecting greater resilience (median, 92) from preintervention to postintervention (median, 97) (z = −2.99, P = .003).
Charge nurses who participated in the training rated higher score responses post survey (Table 4). Challenges to resiliency identified by the charge nurses included agility to system complexities, job role demands, and supervising staff performance. Agility to system complexities included understanding the magnitude of practice and/or technological advancements, as well as the lack of time to embed changes into practice. Job role demands and expectations included finding ways to balance the complexities of the charge nurse role while also being assigned a team of patients for direct patient care. These complexities and resiliency qualities often resulted in a need to be able to recover quickly from challenges and difficulties as the frontline leader for the clinical team. Some charge nurses in this sample managed more than 1 unit at a time and at different levels of care. Identifying the correct balance is a challenge for charge nurses owing to multiple accountabilities. Charge nurses felt that prioritization and delegation of work tasks were a challenge. Supervising staff performance included managing conflict and unprofessional attitudes, leading to confrontational behaviors, lack of staff accountability and performance, and motivating staff. At times, provider performance and behavior were challenging and could be intimidating for the charge nurse.
Qualities that helped charge nurses perform successfully included being a good communicator, honesty and integrity, delegation and empowerment, creativity and innovation, accountability, decision-making capabilities, and being able to inspire others. In addition, a promising sign from the course evaluations is that most charge nurse participants reported that by applying the skills learned in the courses, they would be better able to improve quality, patient experience, cost containment, and team performance/engagement. These areas of performance are not only aligned with organizational goals but also address national health system priorities identified by the Institute for Healthcare Improvement's quadruple aim.18
This project evaluated the creation and implementation of a charge nurse orientation and professional development program at an integrated healthcare delivery system. Like previous researchers, a charge nurse program was noted to be a valuable tool in the progressive development of nurses in this role.19,20 Nursing is a stressful profession due to the emotional involvement needed to care for others, exposure to death and illness, lack of autonomy, lack of management support, physical strains placed on the body, as well as the long working hours.21,22 Similarly, charge nurses have a demanding and challenging role because of all the various expectations and responsibilities in addition to those previously mentioned.2,22 Nurse executives have the responsibility to improve quality and health while reducing cost. As leaders within the healthcare system, charge nurses must also be a part of these positive quality changes while influencing engagement and participation.23,24 The voluminous demands of the charge nurse role add stress to already demanding expectations.2,21,22
Because of the decision to carve out the charge nurse role into a permanent leadership position within the organization, the nurse executive team, as well as the department of organizational learning, was able to focus on development initiatives targeted for this group specifically. As the system embarked on these initiatives, the priority areas determined by nurse executives, charge nurses, and the organizational learning department were resiliency, critical thinking, and decision making, as well as skills in leadership and management. As the system continued on a journey of nursing excellence, additional focus was placed on the charge nurse's role in improving quality outcomes. Of the 22 nurses who participated in the intervention group, 95% (n = 21) indicated that through applying the learnings from the course, participants felt more prepared to improve quality outcomes. In addition, 95% of the charge nurses (n = 21) reported that the courses would enhance their ability to improve team performance.
The investment in charge nurse courses was critical for the development of leadership skills and abilities for nurses functioning in these important roles. Given that stability of nursing leadership has been shown to have an impact on clinical outcomes,19,20 it is important to develop charge nurses as they are frontline nursing leaders. One limitation of this study is the small sample size. Despite this, the authors believed that it was important to disseminate the findings given the significance of the outcomes. The authors recommend continued research on the charge nurse role and effective methods to support charge nurse orientation and professional development. After the initial pilot study, the NCharge courses were offered to charge nurses within the system. Future plans include use of the NCharge courses along with internally developed education programs. In addition, the programs will be measured based on long-term impacts to organizational quality measures for employee satisfaction and engagement. Internal promotions of clinical nurses to the charge nurse role as well as charge nurse promotions to assistant nurse manager and nurse manager roles will also be monitored.
Implications for Nurse Executives
Given the importance and complexity of the charge nurse role, it is critical for nurse executives to invest in the orientation and professional development of this position. Although many hospitals have moved away from nurses serving in a permanent charge nurse position, nurse leaders should consider whether this approach leads to the level of skill development needed for the pool of nurses who rotate in and out of the charge nurse function by shift. From a fiscal perspective, it could also be more costly to organizations to implement orientation and professional development programs for a large pool of nurses who are part of a charge nurse rotation system. Permanent positions for charge nurses, along with role-specific development, may lead to an enhanced level of skill and expertise related to consistency of performance and charge nurse functions. Furthermore, it may support enhanced succession management for the nursing organization as high-performing charge nurses would be better equipped to ascend to assistant nurse manager and nurse manager roles.
As frontline nurse leaders, charge nurses confront many challenges in their daily work, often without the benefit of formal training and intentional professional development opportunities. Closing this gap is key in supporting an ever-changing healthcare environment with key quality indicators such as patient satisfaction and nurse retention. This study shows the benefit of a charge nurse orientation and professional development program with an additional resiliency component. As the literature supports, there must be a commitment of nursing leadership to the establishment of initial and ongoing leadership development for the charge nurse role.
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