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nder The Patient Protection and Affordable Care Act of 2010, the Hos- pital Value-Based Purchasing Pro- gram provides monetary incentives to hospitals for exceeding expectations on various domains, one of which is the patient experience of care

domain.1 The focus on this patient experience domain is now being addressed by the national media. In 2013, $964 million in Medicare funding was tied to patient satisfaction.2 Charge nurses may have a greater impact on patient, physician, and staff satisfaction than any other nurse leaders.3 Charge nurses, frontline leaders who perform complex duties, are untapped resources who can be groomed for future leadership positions.

They desire leadership development and mentor- ing.4 Charge nurses with little or no preparation are often “thrown” into frontline leadership positions that are highly complex, stressful, and critical to the success of a unit.2 Investing in structured leadership training for charge nurses is essential in the current complex healthcare environment.5 The purposes of this quality improvement project were to redefine the charge nurse role using leadership competencies, implement a for- mal charge nurse leadership program on two medical-

surgical units, assess the program’s effect on patient satisfaction with nurse communication, and assess whether the program improves nurse retention.

Education at the forefront There has been little published about charge nurse development programs. However, literature supports the need to invest in charge nurse development. The American Organization of Nurse Executives (AONE) competencies provide structure and metrics for leader- ship development of charge nurses based on a novice to expert scale.6 Key elements of AONE competencies include communication, knowledge, leadership, professionalism, and business skills.6

When comparing leadership skill with other nurs- ing leaders (such as managers or supervisors), several study authors believe charge nurses require addi- tional leadership competencies, including effective communication skills, knowledge of the complex healthcare environment, human resource manage- ment skills, professionalism, and clinical operation skills.6,7 A positive impact on patient outcomes and patient satisfaction has been attributed to charge nurses. Literature suggests a positive relationship between nursing leadership and improved patient

Redefining “charge nurse”

within the front line

By Lorrie Normand, DNP, MS, RN, NEA-BC; Denise Black, MSN, RN, ACNS-BC, APRN; Kathleen M. Baldwin, PhD, RN, ACNS-BC, ANP-BC, GNP-BC, FAACM, FAAN; and Jeannette T. Crenshaw, DNP, RN, NEA-BC, FAAN, IBCLC, LCCE

50 September 2014 • Nursing Management www.nursingmanagement.com

Redefi ning “charge nurse”

outcomes (increased patient satis- faction and reduced patient adverse events and complications).3,8-18 Lack of investment in charge nurse lead- ership skills may put healthcare organizations at risk for underper- forming in a highly competitive healthcare environment.16

Developing the leaders The Plan-Do-Study-Act quality improvement model was used to develop a formal leadership train- ing program for charge nurses at a 137-bed community hospital located in a rural area of Texas.9

Plan An informal focus group of 22 charge nurses and 5 nursing directors was convened by the CNO in October 2012. As an outcome of the discus- sion, the need to redesign the charge nurse role was identified along with a need for leadership training. The CNO formed a redesign team of nurse educators, charge nurses, and the medical-surgical nursing director; the team was assigned to redesign

the charge nurse role and develop a charge nurse leadership program. The long-term goal of this project was to develop, implement, and evaluate an evidence-based program at our hospi- tal that could be used system-wide.

Do The redesign team evaluated the current charge nurse orientation competencies based on clinical expe- rience and input from charge nurses, listed the strengths of the current method of training, and identified opportunities for improvement. From this, the new vision of elevat- ing the charge nurse role to perform as an influential frontline leader was proposed. (See Table 1.) This role expansion was a significant organi- zational change and discussions led to a decision to have current charge nurses reapply for their positions based on new competencies.

To explain the new vision and outline plans for the charge nurse leadership program, the nursing directors, the redesign team, and the CNO conducted an open forum

meeting with current charge nurses. The CNO also conducted face-to- face, hospital-wide, nursing staff informational sessions to solicit feedback regarding the charge nurse role and to provide the opportunity for staff engagement.

The redesign team identified the need for a new charge nurse job description. After evaluating the vari- ous existing charge nurse job descrip- tions used within our 14-hospital healthcare system, the redesign team developed a new charge nurse job description. The team incorporated the best of each existing job descrip- tion, integrated charge nurse expec- tations, and developed the Charge Nurse Commitment letter and Charge Nurse Expectations document. (See Charge nurse expectations and supple- mental content on the Nursing Man- agement iPad app.) Each new charge nurse is required to agree to and sign the commitment letter before starting the leadership program.

In December 2012, charge nurse positions were posted for each nurs- ing unit so that all clinical nurses had

Table 1: Charge nurse program before and after criteria Criteria for charge nurse Before 2013 After 2013

Job description No Yes

Apply for position No Yes

Commitment letter No Yes

Expectations formally outlined No Yes; both helped to motivate the charge nurses toward professional development and feel sup- ported in their efforts.

Structured training Yes; one 8-hour day. Yes; every quarter with the entire charge nurse group. Content based on AONE competencies.

Evidence-based competencies No; charge nurse competencies were identified and based on the entity-specific performance outcomes.

Yes; based on AONE Nurse Executive competencies.

Structured quarterly charge nurse meetings

No; annual update only. Yes: • emphasis on patient outcomes and entity

communication/networking • leadership component • CNO leads meetings.

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the opportunity to apply. Current charge nurses were required to reap- ply for their positions. The hiring process utilized panel interviews with nursing directors and frontline staff. Candidates were selected by the end of December 2012, and the new charge nurse leadership program began with an orientation in January 2013.

The CNO and redesign team determined that the AONE Nov- ice to Expert Leadership Training Curriculum provided entry-level leadership education that was ideal for a novice charge nurse program.5 Because many of our experienced charge nurses lacked formal educa- tion in the role, we also believed they needed the education. The redesign team then identified the leadership characteristics and attributes required for charge nurses based on the system’s pro- fessional practice model, feedback from the charge nurse focus group, and literature published about the charge nurse role. (See Figure 1.)

Changes incorporated into the rede- sign included classes in frontline leadership, career development, service excellence, professionalism, clinical operations, communication, and human resource management. Table 2 lists the schedule of classes offered in the program.

In partnership with the health- care system’s Center for Learning and Career Development, a formal- ized, year-long, classroom-based, instructor-led nurse leadership program for charge nurses was developed. Classes were held for 6 to 8 hours on one day begin- ning in January 2013. Two classes were held in February, and classes were then held every other month through October 2013. Program

instructors were selected from the system’s Center for Learning and Career Development staff based on their areas of expertise with curricu- lum topics. Classes were designed to be interactive and required pre- and posthomework assignments.

Study Two medical-surgical units were evaluated because the majority of the participants in the leader- ship program came from those two units. The leadership program effectiveness was evaluated by comparing patient satisfaction survey scores on three nurse communication questions and the human resources department measuring nurse retention rates for

Charge nurse expectations • Certification in advanced cardiac

life support • Round on all patients • Conduct quality and safety rounds • Ensure core measures are met • Round with physicians, as needed • Attend 3:00 staffing briefing • Conduct beginning-of-shift briefings • Ensure 100% bedside reporting • Conduct survey readiness rounds • Model the promise behaviors • Provide input on performance

evaluations • Attend daily case-management

briefing (N/A for surgical services) • Ensure appropriate staffing per grid • Board certification • Maintain Nursing Career Advance-

ment Program level IV or higher (after achieving board certifica- tion)

• Champion Team STEPPS • Accountable for physician, patient,

and staff satisfaction

Figure 1. Professional practice model characteristics and attributes of nurses

Source: Permission granted by Texas Health Resources, 2014.

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Redefi ning “charge nurse”

the last quarters of 2012 and 2013. Three specific questions about nurs- ing care were measured for this project: (1) Did the nurses treat you with courtesy and respect?; (2) Did nurses listen carefully to you?; and (3) Did nurses explain everything in a way you understand? Nurse retention rates were measured by comparing the overall retention rate in 2012 with the overall retention rate in 2013.

The AONE self-assessment tool was completed by participants at the end of the program to describe their perceptions of improvement in leader- ship effectiveness.6 Based on results of participant self-assessments and nurse leader feedback, participant effective- ness improved in communication, professionalism, and leadership.

Act To support the change, program classes were taped for future charge nurse leadership trainees. Online

charge nurse leadership classes based on the AONE’s certified nurse manager and leader competency program will be utilized for future training and consistent with the for- mal on-site classes offered in 2013.5

This will allow for continued sus- tainability of training for this front- line leader role.

Deploying the trainees A total of 944 patient satisfaction surveys for the medical-surgical units from fourth quarter 2012 (n = 404) and the fourth quarter 2013 (n = 540) were returned and analyzed with statistical software. Cronbach’s alpha was conducted to determine the internal consistency reliability of the questions asked on the survey. The Cronbach’s alpha was 0.716, indicating good internal consistency.

The three survey questions from the Centers for Medicare and Medic- aid Services (CMS) related to nursing communication were analyzed for

the two medical-surgical units using data from the fourth quarter of 2012 (before the program began) and the fourth quarter of 2013 (after program completion). The response options to these questions are on an ordinal scale where higher order indicates a more logical positive response to the question. Group outcome data were analyzed using a Mann-Whitney U (Wilcoxon Rank-Sum) test. (See Table 3.)

We also evaluated nurse retention on the two medical-surgical units. The human resources department tracks nurse retention data for the entity at the unit level. The 2012 RN retention rate for clinical nurses on the medical-surgical unit was 70.52%. The retention rate for 2013 improved to 76.21%, an 8.1% increase.

Closer inspection Although we didn’t find a statistically significant difference, we believe our results are clinically significant. The system’s inpatient satisfaction com- posite score increased by 24% from 51% in 2012 to 63% in 2013. Addi- tional improvements were experi- enced in the organization that may be a result of implementing the charge nurse leadership program. Nurse- physician collaboration was identified in the survey results as a key strength, and each year physicians are invited to participate in a physician satisfac- tion survey. In 2012, 56% of physi- cians responded; 57% participated in 2013. Physician satisfaction improved

Table 2: Charge nurse classes Education classes Schedule

Nurse leader orientation January 2013

Service excellence February 2013

Communication February 2013

Knowledge of the healthcare environment April 2013

Leadership June 2013

Professionalism August 2013

Business skills October 2013

Table 3: Mann-Whitney U (Wilcoxon Rank-Sum) test statistics

HCAHPS question Preintervention mean rank (n)

Postintervention mean rank (n)

P (MW*)

Nurses treat with courtesy/respect 475.33 (n = 404) 470.38 (n = 540) p = 0.611

Nurses listen carefully to you 479.98 (n = 405) 466.88 (n = 539) p = 0.288

Nurses explain in a way that you understand 478.90 (n = 403) 465.97 (n = 539) p = 0.325

*MW, Mann-Whitney U test (Wilcoxon Rank-Sum test)

Significant difference defined as (p < .05) between mean ranks before and after intervention.

www.nursingmanagement.com Nursing Management • September 2014 53

from the 41st percentile in 2012 to the 88th percentile in 2013.

Nurse leaders and physicians have provided positive feedback related to charge nurse leadership effectiveness and increased col- laboration and coordination of care. Nurses in the program provided reflective comments about their experience and indicated increased leadership development and effec- tiveness, interprofessional collabo- ration, and confidence in their roles.

The next recruits Although we experienced positive anecdotal results, we didn’t experience the significant improvement in the patient satisfaction scores we hoped to attain. We may have evaluated these metrics too early in the change pro- cess to see significant change. Projects such as this may require several years to demonstrate significant improve- ment.17 Therefore, continuing this program and reevaluating the results in the future is critical to evaluating the success of the frontline leadership program and improved patient satis- faction in the organization.

In analyzing our results further, we recognized there were several exter- nal variations that weren’t controlled for, which may have influenced our results. A major construction project was in progress on the second floor medical-surgical unit for 5 months in 2013. And, unfortunately, noise can be a factor that negatively influ- ences patient satisfaction scores.18 In addition to the construction project, we experienced unexpected leader- ship, staff, and charge nurse turnover on the two medical-surgical units that were the focus of our project. The reasons for the turnover were multifactorial. A sudden unexpected departure of a director over both units, charge nurses who chose not to participate in the leadership educa- tion (and were going to leave their

charge nurse status), and life-events affecting some nurses were believed to be some of the causes of the turn- over.

Nurse retention is essential for staff satisfaction, quality healthcare, and patient satisfaction.15 We believe that through rebuilding the team, aligning the organization, and increasing sta- bility in leadership, continued moni- toring will show further improve- ment in our patient satisfaction, retention of nurses, and charge nurse leadership effectiveness.

Roll out to other organizations We found that we were able to implement this program effectively within our institution with minimal assistance from the larger healthcare system. Developing highly compe- tent frontline leaders and the use of CMS data in nursing care may provide a significant contribution to knowledge about patients’ views of their hospital experience. Non- parametric statistical methods can appropriately be used for this type of analysis and allow for a thorough evaluation of data. We believe that this quality improvement project can be successfully replicated in other settings, and should be because charge nurses are the first on the frontline to improve patient and staff satisfaction and health. NM

REFERENCES 1. CMS. Hospital value-based purchasing

program. http://www.cms.gov/Outreach- and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/Hospital_ VBPurchasing_Fact_Sheet_ICN907664.pdf.

2. Snyderman N. Hospitals balance patient satis- faction with path to healing. http://www.nbc- news.com/video/nightly-news/52570110/.

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At Texas Health Harris Methodist in Cleburne, Tex., Lorrie Normand is a CNO, Denise Black is a man- ger of Clinical/Community Education and Profes- sional Practice, and Kathleen M. Baldwin is a nurse scientist. Jeannette T. Crenshaw is an assis- tant professor at Texas Tech University Health Sciences Center’s School of Nursing in Lubbock.

The authors have disclosed that they have no financial relationships related to this article.

DOI-10.1097/01.NUMA.0000453274.96005.35