Charge nurses are responsible for the functioning of their units. They must manage day-to-day operations and be skilled in areas of prioritizing, making clinical decisions in a timely fashion, and responding effectively to crises. They are frequently expected to mentor staff, delegate tasks fairly, supervise care, and maintain a safe environment that promotes optimal patient care. Patient satisfaction in the hospital may be influenced by the charge nurses' ability to effectively lead their staff (Delamater & Hall, 2018; Teran & Webb, 2016). For these reasons, providing appropriate and effective training for this role transition is important to the functioning of each unit.
Little research has been conducted regarding preparation of nurses for the transfer to a new unit-based leadership position. Competencies for the role have not been adequately identified (Connelly et al., 2003; Homer & Ryan, 2013). In addition, a formal orientation process and educational preparation for the role rarely occurs (Andronico et al., 2019; Delamater & Hall, 2018). Orientation and ongoing support during role transition to a leadership role such as charge nurse is often lacking (Delamater & Hall, 2018).
One community-based hospital was faced with rapid growth in bed capacity (approximately 90 beds), expanded clinical services, increased patient acuity, and a large volume of new staff. They were also challenged with reducing length of stay. In order to respond to these needs, a leadership model change occurred, and a dedicated charge nurse position was created in both inpatient and outpatient services. To facilitate the charge nurse transition, a 12-month orientation and professional development program, the Baptist Health Orientation and Development Program (BHLODP), was designed for incoming charge nurses. This program is based on Watson's (2005) model of caring, the professional practice model for nursing practice at this hospital, as well as an extensive review of the literature. The purpose of this study was to examine the following two program outcomes: (a) participants' confidence in their ability to be an effective charge nurse and (b) patients' satisfaction before and after the BHLODP.
Literature Review
A review of the literature revealed few studies focused on charge nurse education and development programs. Often charge nurses transition and function in their roles without formal training, orientation, and or leadership support (Delamater & Hall, 2018; Homer & Ryan, 2013; Spiva et al., 2020). Findings from nine studies on charge nurse training demonstrated that a formal orientation process, including developing leadership skills and ongoing support from a mentor, colleagues, and leaders, were needed to be successful in the charge nurse role (Delamater & Hall, 2018). To support success, specific leadership skills, for example, communication and the ability to manage teams, resolve conflict, problem solve, and manage time, were proficiencies required in an education training program (Delamater & Hall, 2018; Flynn et al., 2010; Rankin et al., 2016). Although the learning skills needed for success in the charge nurse role have been identified, a lack of formal orientation and training remains when transitioning to their new role (Patrician et al., 2012; Spiva et al., 2020).
One charge nurse education program focused on developing charge nurses in an outpatient setting. A relationship-based care model was used to build relationships between patients, family caregivers, and colleagues through communication (Andronico et al., 2019). The program was successful at increasing skills, confidence, and knowledge, but it was outpatient focused on an infusion setting, and the focus of this current study was for charge nurses in acute care.
Training methods used across studies varied. A multimodal approach, including case studies, role play, and face-to-face classroom time, is recommended (Delamater & Hall, 2018). Providing relevant training in the skills needed for a charge nurse and taking the time to plan the education were critical for success (Delamater & Hall, 2018). A need remains for research on a multimodal approach to education and the effect on charge nurse confidence as well as patient satisfaction (Delamater & Hall, 2018).
Theoretical Framework
Watson's theory of caring (Watson, 2008) provides the foundation for nursing practice at this institution. Her theory requires respect for all individuals, concern for patients' needs regardless of bias, empathy for those who are suffering, and compassion for all. Within this theoretical foundation, preparing nurses to be successful is an accepted value. It follows that individuals who accept the role of charge nurse need the cognitive and interpersonal skills as well as confidence to accomplish their tasks and responsibilities.
METHODS
Research Design
A quasi-experiment, approved by the community hospital's Institutional Review Board, was conducted. Data on nurses' confidence pre- and postintervention as well as patient responses to five patient satisfaction items were collected. Nurses responded to an investigator-designed questionnaire that assessed their confidence level; patients' scores on five patient satisfaction items were retrieved from the Press Ganey patient satisfaction questionnaire.
Sample and Setting
The sample of nurses selected for the charge nurse role (N = 87) were recruited from the following four hospital units: medical-surgical/telemetry (n = 27), maternity services (n = 21), critical care (n = 25), and emergency department/cardiac catheterization lab/cardiovascular observation unit/surgical services/other (outpatient infusion; n = 14). This study took place in a 393-bed Magnet redesignated community hospital in the southeastern United States. Participants were internal candidates promoted within the organization to the role of charge nurse. At the beginning of the BHLODP, nurses were provided with information regarding the study. Consent was implied if nurses completed the Charge Nurse Orientation and Professional Development Assessment (CNOPDA), and data were collected for analysis pre- and postintervention (12 months).
Measures
Participants' confidence in their ability to effectively perform the charge nurse role was measured using the CNOPDA. This investigator-designed instrument was based on a comprehensive review of the literature (American Organization of Nurse Executives, 2015; Connelly et al., 2003; Flynn et al., 2010; Homer & Ryan, 2013; Leary & Allen, 2006; Maryniak, 2013; Normand et al., 2014; Swihart & Gantt, 2015). Three experts in psychometrics assisted in the development of the 13 items. Four experts in education examined and approved items for content validity.
Items were designed to assess participants' confidence level in the following leadership skills/competencies: communication, teamwork, conflict resolution, interdisciplinary collaboration, patient care decision-making, problem solving, time management, management of organizational resources, staff stress management, self-stress management, maintaining a safe patient environment, staff performance management, and monitoring quality and performance improvement (see Appendix A). Using a 3-point Likert scale (1 = little confidence, 2 = some confidence, and 3 = very confident), participants assessed their confidence level on 13 items designed to reflect these competencies. Total scores (0-39) and responses to individual items were analyzed. Participants responded to the CNOPDA using paper and pencil. The instrument took approximately 5 minutes to complete.
Patient data were retrieved from the Press Ganey survey the quarter before and after 12 months implementation of the BHLODP. For this survey, 30% of patients discharged from the hospital are randomly selected to receive a mailed document to assess patient experience. From the remaining discharged patients who did not receive a mailed survey, 50% are selected to receive an electronic document. Survey data are reported to the hospital the day surveys are returned and monthly reports are immediately available to unit directors.
The Press Ganey survey contained five items of interest. The number do not match items on the survey were identified by the implementation team as relevant to the purpose of this study. These items were (a) "promptness response to call," (b) "nurses kept you informed," (c) "response to concerns/complaints," (d) "staff worked together to care for you," and (e) "did a nurse leader visit during your stay (yes/ no)" based on (1) evidence to suggest that patients are more satisfied with health care when nurse leaders are involved in rounding (Daniels, 2016) and (2) administration's recognition of the importance of leader rounding after reviewing previous Press Ganey scores.
Intervention
The intervention for this study (the BHLODP) was 12 months in length and included a number of activities and learning strategies taken from the literature (Bradshaw & Hultquist, 2017; Peebles et al., 2020). Constructing a leadership team was the first step in developing the BHLODP. The Director of Education, the Executive Director of Administrative Services, a professional development specialist, two directors of nursing units, and the Chair of the Institutional Review Board were selected to participate on the team. In addition to the literature, data from the preintervention CNOPDA was used to design educational strategies for the program. The leadership team designed learning activities that could foster participants' role transition and future success as charge nurses. Data from the preintervention assessment showed that participants rated the following six items (50%): facilitating teamwork and conflict resolution, management of organizational resources, managing the stress of staff, managing my work-related stress, performance management of staff, and monitoring for quality and performance improvement, as areas of educational need. At that time, the following skills and knowledge were identified: communication, conflict resolution, patient experience, healthcare environment/regulations, clinical/nonclinical measures, and dashboards as helpful strategies (Maryniak, 2013; Normand et al., 2014).
An infrastructure was established prior to the orientation that included the development of a dedicated job description with roles and responsibilities, a competency-based orientation and action validation tool, a daily checklist to assist orientees to effectively manage their leadership responsibilities, a copy of "The Effective Charge Nurse Handbook: The Pocket Companion for Charge Nurse Leaders" (Swihart & Gantt, 2015) to support learning and skill acquisition, a standardized charge nurse communication template for e-mails and newsletters, and the CNOPDA. Under the guidance of the Director of Education, the team designed learning activities related to these competencies to be covered in the orientation workshops.
Two half-day orientation workshops included major concepts from the literature and incorporated engaging teaching strategies to promote learning. Concepts such as the hospital's care delivery model, role expectations and orientation, daily operations (coordination and delivery of patient care, patient flow, staffing/assignments, decision-making/handoffs), patient experience and leader rounding, sustaining a culture of safety and patient safety, professionalism, peer networking, team building, nurse-sensitive indicators, keeping the department Environment of Care survey ready, delegation, and accountability were addressed. Learning strategies were modified over time based on participants' responses to the CNOPDA at 3, 6, and 9 months. Results were used to identify areas of greatest need in relation to participants' confidence in their ability to perform specific skills/competencies. Educational activities were modified to address these areas of need at each interval in order to strengthen the learning experience.
This method of ongoing assessment is related to performance management. Performance management encourages experiential learning over time so that individuals can gain confidence and transition more easily to new roles. The ongoing assessment and modification of learning activities are reported in the literature as effective means for enhancing the professional development process (Swearingen, 2009). A cycle of ongoing charge nurse professional development, implementation of intervention, and reassessment was utilized (see Figure 1).
A number of active teaching strategies and concepts to enhance learning were used throughout the program (Bradshaw & Hultquist, 2017). Strategies included videos, e-learning modules, expert presentations, formal assessments, focus groups, role playing, reflection, table group discussions, problem-based learning, and panel discussions. Examples of specific content included nurse-sensitive indicators, Joint Commission requirements, aspects of medical record system (EPIC) related to charge nurse duties, strategies to enhance conflict resolution, and leader rounding. During one of the sessions, a formal presentation on the importance and value of leader rounding, an introduction to standard scripting, and the essential components of rounding were discussed, followed by scenario-based role playing by participants. Each participant's competency on leader rounding was validated in their practice setting using a competency tool.
Additional examples of active teaching strategies used in the BHLODP and collected concepts from participants from the 2019 Association for Nursing Professional Development Conference presentation have been compiled (see Table 1).
Throughout the program, "just-in-time" education was provided for identified participant needs before organizational events occurred. Just-in-time education provides "on-the-job," work-based, time-relevant teaching as it is needed relating to a charge nurse role (Peebles et al., 2020). In this program, the education facilitated a timely application of the new skills. For example, issues related to evaluating staff performance were identified as a need in the preintervention CNOPDA. Given that evaluations of staff performance were due in the next quarter, an education program was developed and implemented to prepare charge nurses to perform this task.
Activities regarding communication, such as monthly meetings for the first quarter, were held for all participants in order for them to relate to each other in a meaningful way and interact with team members regarding their new roles. These meetings transitioned to quarterly to provide ongoing education based on the CNOPDA assessments. In addition, continuing education was offered throughout the program for those individuals who wanted to access specific topics.
Data Analysis
Data were entered and analyzed using SPSS Version 25 (Armonk, New York). Data on nurse participants (pre N = 87, post N = 51) were retrieved from the pre and 12-month CNOPDA assessments. An independent t test was calculated. Descriptive statistics were used to assess patient responses to care provided before and 3 months after the intervention.
RESULTS
Nurses Confidence Level
There was a statistically significant increase in the CNOPDA total scores from pre BHLODP (M = 33.1, SD = 3.8) to postintervention (M = 36.5, SD = 2.6), t(128) = -5.5, p = .005. The mean increase in total CNOPDA score was 3.4, with a 95% CI [2.15, 4.53]. Responses to 13 items were also examined. A positive direction occurred for each of the 13 items (see Table 2).
Patient Responses to Five Items
Little change occurred in four of the five patient satisfaction items. At preintervention, 82% of patients (N = 411) responded yes to the item "a nurse leader visited during my stay." This percentage increased to 90% (n = 404) following the intervention.
LIMITATIONS
Limitations of this study include (a) drawing a sample from one community hospital in the southeastern United States and (b) a potential problem related to participant bias when the same instrument is used to assess learning needs and measure outcomes. A possibility may exist that participants could have simply recalled items on the CNOPDA when responding at 12 months. In addition, although the content validity was addressed, it was not tested for reliability. Future recommendations include conducting a test-retest reliability assessment on this instrument and designing a tool to assess the charge nurse program on patient satisfaction and outcomes. Finally, the Press Ganey data set may not be the strongest indicator of change as a result of the charge nurse orientation program.
DISCUSSION
The charge nurse role is essential to the effective functioning of a hospital unit. Little attention, however, is paid to preparation for these individuals (Sherman et al., 2011). Insufficient training of charge nurses can impact workflow, patient care, and staff and patient satisfaction (Andronico et al., 2019). The current study evaluated the implementation of a professional charge nurse orientation and development program in a 393-bed Magnet redesignated community hospital. Participants' confidence in performing required aspects of the charge nurse role and patient satisfaction before and after the program were examined.
Analysis of total confidence scores revealed an increase in participants' confidence in their ability to perform the charge nurse role when assessed at two time points (i.e., preassessment and 12 months). It appears that self confidence in all 13 areas reflected in the questionnaire improved in a positive direction. This increase in nurse confidence is supported by findings in a qualitative study conducted by Flynn et al. (2010).
An ongoing challenge is managing stress in patient care areas; "managing the stress of staff" and "managing my work-related stress" remain as opportunities for further intervention and support. Charge nurses' lack of confidence in managing occupational stress for themselves and staff is reported in the literature (Kath et al., 2012; Labrague et al., 2018; Shirey, 2006; Shirey et al., 2010; Van Bogaert et al., 2014). Charge nurses at the end of 12 months in this current study were slightly more confident in addressing staff stress than addressing their own.
The BHLODP was uniquely designed in that activities were modified following each time participants responded to the CNOPDA. Changes were made based on needs revealed by responses to this instrument. Opportunities were provided to participants following each assessment to learn both in classes and experientially throughout the year so they could increase confidence in areas where they needed support. Experiential learning use in developing charge nurse leaders is also supported by Johnson et al. (2010). One example of experiential learning implemented during this program was the use of the unit-specific National Database of Nursing Quality Indicators nurse-sensitive indicators outcome data. Charge nurses were taught how to prioritize unit-based indicators using a metric prioritization table that is included in a tool kit from the nursing executive center (Nurse Manager Guide to Improving Outcomes, 2016). Once identified, they were taught how to conduct focus group assessments regarding specific indicators with the nurses on their shift. A focus conversation with three to four high-performing staff occurred. The charge nurse was then encouraged to "manage up" with the collective information gathered during the focus group discussion to the unit director. As a team, director and charge nurses determined specific unit barriers and developed action plans for implementation.
Charge nurses play a role in the delivery of quality patient care and advancing a positive patient and family experience. Minimal change occurred regarding patient satisfaction in this study from the Press Ganey survey results. Patients responded to the question "they were visited by a nurse leader during their stay" more positively postprogram. This change may be due to one education session during the charge nurse orientation specifically focused on rounding. Rounding, by charge nurses or leadership, demonstrates an important component of improving the patient experience (Campbell & Thompson, 2007; Frankel et al., 2008; Kline & McNett, 2019; Reimer & Herbener, 2014). The education for rounding involved role playing and a competency/validation tool that was used by an experienced nurse leader who provided assessment and feedback. Following this training, nurses may have felt more confident in performing leader rounds. Costanzo et al. (2019) also found that, in learning the skill of interprofessional rounding, nurses were tentative at first but improved over time.
IMPLICATIONS
Findings from this study suggest that formally addressing learning needs as nurses transition from a clinical role to a leadership role can improve individuals' confidence in their ability to perform necessary tasks. The unique intervention that continually examined learning needs and evaluated outcomes may also have contributed to the positive change that occurred over time. Hospital administrators can consider using this method to enhance role transition or at least formally address development of leadership roles.
Future Research
Future research could include various healthcare settings and the development of a patient satisfaction instrument specifically designed to assess changes in patient experience relative to the charge nurse role.
CONCLUSION
It appears that formally attending to role transition from clinical nurse to a charge nurse can improve nurses' confidence in their ability to successfully perform that role. For example, charge nurses' confidence in providing a safe environment for patients improved over the year. This change is important as hospitals continuously monitor key indicators, such as falls, to ensure quality patient outcomes. Confidence in the charge nurses continued to improve, with purposeful support, over the 12-month transition period.
ACKNOWLEDGMENTS
The authors would like to acknowledge the following; Karen Hill, DNP, RN, NEA-BC, FACHE, FAAN; Kathy Tussey, MSN, RN, NEA-BC; Laura Senn, MSN, RN, RNC-OB; Dee Beckman, DNP, MBA, MSN, RN, NE-BC; Melissa Perry, MSN, RN, CNML, NE-BC; and Whitney Heet, MSN, RN, from the charge nurse leadership team at Baptist Health Lexington. They would also like to thank the leaders throughout Baptist Health Lexington for their contribution to this program; Lonnie Wright, MSLS, for his library assistance; and the Nursing and Allied Health Research Office. The primary author would also like to acknowledge the attendees from the 2019 Association for Nursing Professional Development Annual Convention Concurrent session who contributed the ideas to the learning concepts and strategies.
References