How to Be an Effective Charge Nurse
Excellent communication skills, flexibility, clinical competency and ability to make quick decisions required.
By Nancy Blake, PhD, RN, CCRN, NEA-BC, and Colleen Young, BSN, RN, CCRN Print Article
To view the Course Outline and take the exam online, click here. For a printer-friendly version of the exam you can print out, complete and mail to ADVANCE, click here. Learning Scope #418 1 contact hour Expires Jan. 28, 2015 You can earn 1 contact hour of continuing education credit in three ways: 1) Grade and certificate are available immediately after taking the online test. 2) Send the answer sheet (or a photocopy) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-2781426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better. Merion Matters is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Matters is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298). The goal of this continuing education offering is to provide the latest information to nurses about how to be an effective charge nurse. After reading this article, you will be able to: 1. List eight themes to describe the role of the charge nurse. 2. Describe the items required when delegating. 3. List four items that should be covered in a charge nurse workshop. "From the most colossal calamities, down to the most trifling accidents, results are often traced (or rather not traced) 1 to such want of someone in charge or of his (or her) knowing how to be in charge." The role of a charge nurse is unpredictable. It requires a person with excellent communication skills who is flexible, clinically competent and able to make decisions quickly. Little research has been done to examine this role and only a 2-4 few articles describe charge nurse competencies. Eggenberger describes eight themes to characterize the role: 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 4 happy. An effective charge nurse can make the difference for the unit during their shift and can create a positive work environment for the staff, patients and their families. This article will examine how to be an effective charge nurse. There will be an overview of the charge nurse's role, followed by a discussion on charge nurse leadership, conflict resolution, delegation and communication.
Role of the Charge Nurse As mentioned above, little literature exists about the role of the charge nurse, even though it is a well-established position in hospitals. Charge nurses function as frontline managers often without training to support them in their role. Most are senior nurses who possess clinical competence, but that does not ensure they possess the leadership skills necessary to function in the role. An effective charge nurse needs to incorporate leadership and communication skills with conflict resolution, time management and organizational techniques, delegation, mentorship, education, and role modeling to be successful. These individuals also must be effective change agents to get what they need accomplished on a day-to-day basis. The charge nurse role may be a permanent, relief or rotational position. There also are various titles used for this role such as lead, unit supervisor or assistant nurse manager. These individuals, depending on the hospital, may perform managerial tasks such as performance evaluations, interviews, scheduling, payroll, signing off on staff competencies and budgetary duties as they pertain to staffing. More and more, charge nurses function as a liaison between middle management, staff, physicians, patients and families, ancillary staff and other departments. They represent the nursing management team 24/7. Charge nurses are accountable to many people, first and foremost to the safety and care of the patients/families on their units, the staff they lead and the institution that employs them. But they also must hold staff members (direct and indirect) accountable to provide safe and appropriate care. It is a difficult position because one day they may be in charge and the next day they are a peer to the staff that they supervised the day before. One hospital actually titled their charge nurse workshop, "How to be a great nurse leader 3 when you are not the boss." The topics of this workshop include communication, supervision and delegation, conflict management and team building. Charge nurses must ensure staff members have appropriate training and qualifications for the patient assignment and match the staff's competencies with the needs of the patient. As a leader on their shift, they also need to assure adequate resources are available, policies and procedures are followed, and regulatory requirements are met. The charge nurse wears many "hats" simultaneously. They have been equated to air traffic controllers and are often described as the "go-to" person, the one to get things done or the resource that has all of the answers. Their responsibilities may extend beyond staffing the unit. They function as a resource to the staff on the unit, other departments and disciplines, and even physicians. Charge nurses possess more than clinical expertise. They are problem-solvers and usually can recognize a potential problem before it arises. Exemplary leadership and communication skills also are essential in this role. Berbarie lists the characteristics necessary to be effective charge nurse: educator, change agent, innovator, mentor, leader, 5 mediator, financial steward, evaluator and celebrator. Such complex working conditions for the charge nurses have been described as comparable to high-reliability, nonhealth-related jobs, such as those working on launch pads for spacecraft, nuclear power plants and fighter jet carrier flight decks.6 Researchers describe five effective decision-making behaviors for staffing resourcefulness, tactful communication, flexibility, decisiveness and awareness of the big picture.6 Resourcefulness is not having all the answers but knowing where to find answers. That includes knowing about the patients on the unit, potential admissions and patient populations on other units, staff's abilities, equipment, diagnosis, therapies, studies, policy and procedures. Another key competency is to be flexible because the plan for their shift often changes. These nurses need to be open to other ways of doing things, particularly when it comes to unplanned admissions. Staff may frequently be requested to change their assignments based on the patient's or unit's needs. Charge nurses constantly make decisions on a minute-to-minute basis, so they must be decisive and understand patient flow. These individuals set the tone for the unit during their shift and can influence the tone for the oncoming
shift. They can make or break the unit. There needs to be confidence in their decision-making skills. They are aware of the big picture as well. Charge nurses are present on the unit and can anticipate problems that might arise and divert disaster. They know their staff's strengths and weaknesses, recognize escalating stress and intervene to maintain calm. They continually make patient rounds, are aware of patient acuity and are available to staff, patients and families. Leadership Charge nurses possess transformational leadership, which means they commit people to action, and convert 7 followers to leaders and leaders into change agents. Kouzes and Posner describe transformational leadership using five aspects: challenge the process, inspire a shared vision, enable others to act, model the way and encourage the 8 heart. Kouzes' and Posner's style of leadership is the most common leadership style for charge workshops identified in the literature. Leaders challenge the process and are not satisfied with the status quo. They're innovative, willing to take risks and experiment to find new ways of doing things. Leaders are change agents and problem solvers. Charge nurses are leaders. They inspire a shared vision and have a desire to change the way things are and enlist the support of others by being agents of change. Charge nurses understand the needs of others and keep their interests in mind, especially with decision-making. They also enable colleagues to act by strengthening others through teamwork, encouragement and empowerment. Charge nurses model the way with professionalism and dedication and set an example for others to follow. These individuals encourage the heart through recognition of others. Celebrating staff's accomplishments, mentoring and the love of the job they do are ways to encourage the heart. It has been said, "Nursing is the finest art." Founded on a vision by Florence Nightingale, nursing also is a service to others. These are all encompassed in servant leadership -- an additional leadership style. Hunter defines true leadership not as power but authority based on relationships, love, service and sacrifice by strengthening the bonds 10 of respect, responsibility and caring for those you lead. It goes without saying charge nurses need to have a high degree of emotional intelligence. Emotional intelligence is 11 the process that influences one's ability to respond to others while managing one's own feelings. It is more important than IQ. Emotional intelligence is self-awareness, self-regulation, motivation, empathy and social skills. Emotional intelligence creates a positive and productive work environment. Communication Tactful communication skills are important. Charge nurses are constantly communicating with staff, patients, families, physicians, supervisors, managers and other employees or non-employees. Being able to communicate in a concise, supportive, non-threatening manner takes skill and practice. Researchers say that up to 90% of communication is non-verbal. Body language, facial expressions, posture, timing, tone and location can have considerable impact on communication. Effective listening skills also are part of effective communication. Nine percent of the day is spent writing, 16% 12 reading, 30% speaking and more than 45% listening. To become better listeners, and thus better communicators, one must: look at the speaker, don't interrupt, focus on understanding, check one's own emotions, suspend judgment, determine the immediate need, sum up the conversation, clarify any misunderstandings and make listening a 12 priority. Listening increases knowledge, generates ideas, builds relationships, exhibits respect for others and promotes teamwork. As a profession, nurses tend to excel in communication because they know how to listen and encourage. Communication is the transfer and understanding from one person to another and includes the message, non-verbal behavior, (tone, expressions, gestures, posture, pauses, etc.) and process (ideation, encoding, transmission, receiving, decoding and response). Ideation is the message itself; encoding is the manner in which it is conveyed (including non-verbal communication); transmission of the message by the receiving party; decoding is the 13 interpretation of what is being said; and response is any feedback. Effective communication establishes and 13 promotes professional competence to ensure quality patient care. Charge nurses must foster a positive and safe environment that allows for open and respectful communication which
results in trust. The most important aspect of communication is listening. Charge nurses need to possess assertive communication skills and be careful that it doesn't turn into passive or aggressive communication. Assertive style of communication takes into account the rights of others and incorporates direct eye contact, spontaneous verbal expressions, appropriate gestures or facial expressions, confidence and speaking in a well-modulated tone. Assertiveness is an acquired process that stems from maturation in a role, experience and self-confidence in one's knowledge and abilities. Delegation Delegation itself is another part of communication. It is the process of assigning others responsibility and authority. Through delegation, the unit can function in a more efficient and effective manner, but more importantly, delegation can help employees in developing their own skills. Delegation requires a clear description of the task, the responsibilities and authority associated with it, time limits and expected outcomes or goals. Keep in mind the task delegated must be in alignment with their scope of practice and competence level. Charge nurses are still held accountable for their decisions and the tasks they delegate. The role of the charge nurse takes on the highest form of delegation in nursing. Being in charge is not just about doing nursing tasks oneself or appointing others tasks, but it includes ensuring that staff members complete the tasks assigned to 14 them. Conflict Resolution Conflict resolution is one of the things charge nurses dislike the most. Nurses traditionally take a passive approach to conflict management, smoothing over the situation and not addressing it directly. This type of conflict resolution is usually used with a co-worker or a physician. The charge nurse doesn't want to confront the behavior for fear that it will only make matters worse. This tactic may result in things exploding in the future. There are a few easy strategies to resolve conflict. First, recognize the conflict and address it early. This requires paying attention to body language and subtle cues. Second, be proactive. Address the issue or problem before it becomes a major conflict. A good example of this is when family members request a second opinion for something going on with the patient. Have someone else go in and check to help relieve their anxiety. Third, be an active listener. Nothing sets people off more than when they feel they are being ignored or patronized. Fourth, remain calm. It is easy to become emotional, but it is not worth getting into a volatile discussion that ends in yelling and a 15 confrontation. Fifth, seek a solution. Work to come up with a solution or a compromise good for both parties. Invest in Development The charge nurse role is a difficult position that requires preparation. Many hospitals provide workshops along with a clinical orientation with a preceptor, which is usually for three shifts. The workshops cover key competencies necessary for the charge nurse, including leadership, communication, delegation and conflict 16,17 resolution. Organizations need to invest in the leadership development of the charge nurse as it is linked with patient safety and healthy work environments.