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AN EDUCATIONAL TRAINING PROGRAM FOR CHARGE NURSES ON PROMOTING
UNDERSTANDING AND THE BENEFITS OF INTEGRATING TRANSFORMATIONAL
LEADERSHIP STRATEGIES
By
A Project
Submitted to the Faculty of D’Youville Division of Academic Affairs
In partial fulfillment of the requirements for the degree of
Master of Science
In
Nursing Management and Quality Leadership
Buffalo, NY
Copyright © 2022 by …….All rights reserved. No part of this project may be copied or reproduced in any form or by any means without the written permission of ……
PROJECT APPROVAL
Project Committee Chairperson
Name:
(Typed)
Signature:
Discipline: Nursing
Project Defended
On
January 27th, 2022
Abstract
The charge nurse (CN) is the frontline leader in most healthcare settings and is the most accessible to nursing and interdisciplinary staff on shift in addressing clinical and administrative concerns. The CN is a frontline leader who often receives little to no initial training and lacks ongoing professional and leadership development. Transformational leadership (TL) is an approach where leadership capacity of others is developed, inspires team members to achieve great results and places emphasis on a value system. Integrating TL strategies in the CN role, has potential to positively impact healthcare delivery. As frontline leaders, CNs are well equipped to embrace TL strategies because of their background as clinicians and experience as frontline leaders. The purpose of this project was to develop an educational training program for charge nurses working in an emergency department of a pediatric hospital to promote understanding regarding the importance and benefits of integrating transformational leadership strategies in their role as frontline leaders. Patricia Benner (1984) From Novice to Expert Theory was utilized as the theoretical framework for the development of this project. Five content experts voluntarily participated in the final review of the educational training program for content validity.
Table of Contents
Chapter
I. PROJECT INTRODUCTION…………………………………………….. 7
Statement of Purpose……………………………………………………… 7
Theoretical Framework……………………………………………………. 7
Literature Synopsis…………………………………………………............ 15
Significance and Justification……………………………………………… 16
Project Objectives………………………………………………………….. 17
Definition of Terms………………………………………………………… 18
Limitations…………………………………………………………………. 19
Project Development Plan………………………………………………….. 19
Plan for Protection of Human Subjects…………………………………….. 20
Plan for Project Evaluation…………………………………………………. 21
Summary……………………………………………………………………. 22
II. REVIEW OF LITERATURE………………………………………………. 24
Summary……………………………………………………………………. 30
III. PROJECT DEVELOPMENT PLAN……………………………………….. 31
Project Setting and Population……………………………………………… 31
Content Expert Participants………………………………………………… 31
Data Collection Methods…………………………………………………… 32
Project Tools………………………………………………………………... 32
The Protection of Human Subjects…………………………………………. 33
Summary……………………………………………………………………. 34
IV. PROJECT EVALUATION, IMPLICATIONS, AND FUTURE
RECOMMENDATIONS…………………………………………………… 35
Project Evaluation…………………………………………………………... 35
Implications for Future Practice…………………………………………….. 41
Future Recommendations…………………………………………………… 41
Summary…………………………………………………………………….. 42
References…………………………………………………………………… 44
Appendices…………………………………………………………………… 48
List of Appendices
Appendix
A D’Youville Patricia H. Garman School of Nursing Full Approval Letter…………. 48
B Letter of Intent……………………………………………………………………… 50
C Evaluation Tool…………………………………………………………………….. 52
D Educational Training Program……………………………………………………… 55
E Survey tool results in graph…………………………………………………………. 67
CHAPTER I
The charge nurse (CN) role embodies myriad of responsibilities not limited to staffing, conflict management, interdisciplinary communication, and delivery of high-quality patient care. The role is an extension of the nursing leadership team but receives limited initial and ongoing training (Spiva et al., 2020). To ensure CN success, emphasis should be placed on the importance and benefits of integrating transformational leadership (TL) strategies in the role. According to Broome and Marshall (2021), TL is described as an approach where leadership capacity of others is developed, inspires team members to achieve great results and places emphasis on a value system. Behaviors of TL leaders include idealized influence, inspiration and vision, intellectual stimulation, and individual consideration (Broome & Marshall, 2021).
Integrating TL strategies in the CN role, has potential to positively impact healthcare delivery. As frontline leaders, CNs are well equipped to embrace TL strategies because of their background as clinicians and experience as frontline leaders. This is supported by Spiva et al. (2020) who found 95% of CN participants felt more prepared to meet quality outcomes and improve team performance after partaking in a training program on leadership and resilience. Supporting TL strategy integration by CNs will further develop their leadership capabilities as frontline leaders and ensure those on their team deliver healthcare patients deserve.
Statement of Purpose
The purpose of this project was to develop an educational training program for charge nurses working in an emergency department of a pediatric hospital to promote understanding regarding the importance and benefits of integrating transformational leadership strategies in their role as frontline leaders.
Theoretical Framework
Patricia Benner (1984) From Novice to Expert Theory was utilized as the theoretical framework for the development of this project.
A brief overview of the theory was presented as well as a discussion regarding how the theory was utilized to guide the development of the educational training program. In addition,
Benner’s (1984) theoretical definitions for nursing’s four metaparadigm concepts (nursing, health, person, and environment) as well as the Project Author’s operational definition for nursing’s four metaparadigm concepts were presented.
Novice to Expert
Patricia Benner is best known for her adaptation of the Dreyfus model of skill acquisition. The Dreyfus model of skill acquisition applied to nursing includes five stages. These are: (1) novice, (2) advanced beginner, (3) competent, (4) proficient, and (5) expert (Benner, 1984). Benner explained each of these stages and its application to nursing. She furthered these stages by explaining each phases implication on teaching and learning. The premise of the five stages is based on Benner’s proposition the nurse develops expertise when embedded knowledge can be applied to clinical scenarios due to possession of principle-based knowledge (Benner, 1984). While the nurse progresses through the five stages, they build on principle-based knowledge with clinically based experiences (Benner, 1984).
In addition to adapting the Dreyfus model of skill acquisition, Benner suggested the phrases “knowing that” (i.e., principle-based knowledge) and “know-how” (i.e., clinically acquired skills). Benner identified that “know-how” and “knowing that” can occur independent of each other (Benner, 1984). The “know-how” is used to extend practical knowledge through theory-based scientific investigation and documentation of findings (Benner, 1984).
This is a key point to understand in Benner’s theory because she believed failure to document clinical findings deprived the nursing profession of knowledge embedded within practice (Benner, 1984). Therefore, extension of practical knowledge (i.e., “know-how”) through theory-based scientific investigations was important to give weight to practical knowledge and explain gains of the nurse who becomes an expert. It is combination of principle-based knowledge and clinically based experiences that leads to development of the expert clinician (Benner, 1984). In addition to explanation of the five stages in Novice to Expert, Benner explained the implications of teaching and learning for advanced beginners to experts. This is noteworthy as Benner’s theory is based on skill acquisition and implies an element of teaching and learning must occur to graduate through the theory’s stages until the expert stage is reached.
The first stage in Benner’s Novice to Expert is the novice. In this stage, the novice practitioner does not possess previous knowledge or experience to draw from in situations they are expected to practice (Benner, 1984). In the novice stage, the nurse is taught principles and objective information required to help guide their practice since the novice nurse does not have contextual understanding of knowledge they were taught (Benner, 1984). Despite, having principle-based knowledge, the novice is bound to practice solely on theories taught and are limited in ability and scope to apply theories and knowledge beyond examples they identify
(Benner, 1984).
The second stage in Benner’s Novice to Expert is the advanced beginner. In this stage, the advanced beginner practitioner begins to apply principles they possess but require assistance of more experienced practitioners to ensure patient needs are met (Benner, 1984). The advanced beginner demonstrates they can perform tasks in a marginally acceptable manner (Benner, 1984).
In this stage, the nurse requires an instructor to provide guidelines and comprehension is predicated on the advanced beginner possessing basic knowledge to carry out the task at hand (Benner, 1984). The advanced beginner is focused on carrying out duties outlined by the instructor and are unable to prioritize and will complete tasks despite what is happening around them (Benner, 1984). The advanced beginner lacks appreciation of the whole situation and requires assistance in identifying key findings during assessments to ensure safety of patients and themselves as practitioners (Benner, 1984).
The third stage in Benner’s Novice to Expert is competent. In this stage, the competent practitioner has been in the same or similar situations for two to three years and is able to plan and prioritize tasks that are to be completed (Benner, 1984). The competent practitioner can manage arising situations but lacks speed and flexibility of the proficient nurse (Benner, 1984). In this stage, the competent practitioner would benefit from decision-making games and simulations to aide in their ability to manage multiple and complex patient care demands (Benner, 1984). In this stage, the competent practitioner builds on practical and theoretical knowledge. Exposure to past clinical scenarios instills confidence in the competent practitioner to begin applying knowledge gained from previous clinical experiences to make decisions about current situations (Benner, 1984). Their decision-making can be supported by held theoretical knowledge.
The fourth stage in Benner’s Novice to Expert is proficient. In this stage, the proficient practitioner perceives situations as a whole, based on previous knowledge and experience (Benner, 1984). Decision-making is easier because they can identify what information being presented is key to long-term planning in care delivery (Benner, 1984). Furthermore, the proficient practitioner can identify subtle information which may go unnoticed by the novice to competent practitioner, aiding in appropriate and timely care delivery (Benner, 1984). In this stage, the proficient practitioner benefits from case studies to apply experience and knowledge (Benner, 1984). To refine skills, the nurse should be asked to cite examples from practice to gain perspective (Benner, 1984). In this stage, the nurse begins to rely on experience rather than theory (Benner, 1984). The proficient nurse views theory as needed by new learners to approach situations safely and not applicable to more complex scenarios (Benner, 1984). Proficient performance is found in those with three to five years of experience in an area (Benner, 1984). At this stage, one begins to see the divergence of knowledge gained through theory and knowledge gained through experience to guide decision-making.
The fifth and final stage in Benner’s Novice to Expert is expert. In this stage, the expert practitioner does not rely on theoretical knowledge to guide decision-making; rather, the nurse guides decision-making based on clinical experience and instinct (Benner, 1984). It is important to note, Benner (1984) explained the expert practitioner uses theoretical knowledge when faced with an unfamiliar situation or when their conclusion or actions in a situation were incorrect. During this time of reflection, the expert practitioner can identify errors and find explanations in situations based on previously learned theories. Although expert is the final stage in Benner’s theory, there is ability to extend this theory regarding implications for learning and teaching in this group. Systematic and qualitative documentation of expert practitioners has potential to develop new areas of clinical knowledge (Benner, 1984). Since expert clinicians guide decision-making through experience, a level of formalism is lacking to capture all steps taken by an expert
(Benner, 1984).
Novice to Expert Theory and Nursing’s Metaparadigm
Although Benner did not outwardly and explicitly define nursing’s four metaparadigm concepts (nursing, person, health, and environment) in her Novice to Expert theory, she described them as follows.
Nursing is described by Benner (1984) as a helping role; one in which the nurse ensures the patient does not feel a sense of obligation and the nurse takes on the responsibility to provide a holistic approach to caring. A formal exchange between nurse and patient is not required for the nurse to take on the helping role (Benner, 1984). Furthermore, the nurse according to Benner (1984) is also that of teacher and coach. As a teacher and coach, the nurse sets out targets for the patient to reach and helps them to reach these goals (Benner, 1984). Therefore, when a patient is not meeting goals or taking actions towards healing, sometimes the nurse will take over (Benner, 1984). The authoritative way this occurs is temporary to prevent harm to the patient and since there is no need to formalize the relationship between nurse and patient, a power imbalance exists allowing for an authoritative stance in some aspects of nursing. Nursing, for the purpose of this project was operationally defined as a CN in one of Benner’s five stages of skill acquisition. Additionally, nursing, for the purpose of this project was defined as the TL strategies engaged by the CN. Like Benner’s definition, the relationship between CN and team members is not formally expressed and goal of CNs is to help and support team members to delivery care to patients while incorporating TL strategies. Furthermore, for the purpose of this project, nursing was goal-oriented to meet needs of patients, colleagues, and the organization. The CN encourages engagement from colleagues and allows them to be active participants and guide decision-making. It is only when there is a safety risk to staff, patients, or organizations that the
CN will exercise authoritative behaviors temporarily until safety is restored.
Benner did not specifically define environment. Benner and Wrubel (1989) used the term situation because it “implies a social definition and meaningfulness” (Benner & Wrubel, p. 80). Situation denotes a place to stand and be and refers to situation and situatedness (Benner & Wrubel, 1989). Situation and situatedness are best understood in the perspective they offer. One refers to either being inside the situation, whereas the other refers to an observer looking in respectively (Benner & Wrubel, 1989). The person needs to have a grasp on their situation to function; therefore, their behaviors are influenced where they are in relation to the situation.
Environment, for the purpose of this project was operationally defined as the emergency department and the ability of the CN to lead and address issues arising from this area. Most of the CNs work centered around the emergency department but e nvironment could be extended to include the organization because interdepartmental communication is required when coordinating patient care. Therefore, environment of the CN included any place in which ER staff and patients were located and were receiving or providing care.
Health is not clearly defined by Benner. Benner and Wrubel (1989) differentiated between illness and disease and postulated they are mutually inclusive. Illness is defined as the
“experience of loss or dysfunction” and disease refers to what “occurs at the cellular, tissue or organ level” (Benner & Wrubel, p. 8). Health refers to the lived experience of the person and therefore carries a different meaning to each person (Benner & Wrubel, 1989). Health, for the purpose of this project was operationally defined as leadership. Health is interpreted as the CN’s previous experiences and how that translated in their role as leader and perception of their leadership abilities. The CNs view on health would change over time since experiences challenge current ideas and values. CN leadership capabilities and departmental and organizational policies affected CN health; thus, the level of inclusion of TL strategies by CNs was related to their health. A healthy CN will include TL strategies compared to the unhealthy CN who would be less inclined to implement TL strategies.
Person is described by Benner (1984) as the senses of personhood, meaning, and dignity. When the nurse is caring for the person, it is these matters that are being tended. Regarding person, Benner (1984) differentiated between doing for and being with a patient. The main thinking in nursing is to cure the patient and to contribute to the person (Benner, 1984).
Nevertheless, among expert nurses, they can identify when to do and when to be with patients
(Benner, 1984). Furthermore, person according to Benner and Wrubel (1989) was conceptualized to include the role of temporality, role of body, role of personal concerns and role of situation. Role of temporality is “specific and formed by what has gone on before and by what is anticipated” (Benner & Wrubel, 1989, p. 67). Ability to manage stress and cope are shaped by temporality (Benner & Wrubel, 1989). Benner and Wrubel (1989) defined role of body as embodied intelligence. Mind and body were discussed by Benner and Wrubel. In some instances, the person performs based on instinct and this heightens their bodily responses to situations (Benner & Wrubel, 1989). In instances where the person responds to what is happening around them, this dampens internal sensations (Benner & Wrubel, 1989). Here, one can see how the relationship between mind and body interrelate as the nurse progresses through the stages of skill acquisition. Body plays a stronger role in the earlier stages of Novice to Expert compared to mind which plays a larger role in the later stages of the theory. Mind and body are interrelated, and their influence correlates with the stage of skill acquisition of the nurse. Role of personal concerns is a qualitative measure referring to the person’s level of involvement (Benner & Wrubel, 1989). Furthermore, role of personal concerns refers to internal motivations and cues intuited by the person that influences behaviors and decision-making (Benner & Wrubel, 1989).
Role of situation refers to how the person is involved and their understanding of the situation (Benner & Wrubel, 1989). Person, for the purpose of this project was operationally defined as the follower (i.e., the one led by CNs). Regarding person, this relates to the follower’s ability to engage in a transformational relationship with the CN. Comparable to Benner’s definition, the Project Author differentiated between doing for and being with regarding the CN. The CN must know when they need to take directive stance with the team and when they should allow the team to navigate situations on their own. Additionally, the CN builds on experience to influence leadership behaviors through temporality, body, situation, and personal concern. It is these matters that influence the relationship between the CN and person.
Benner’s Novice to Expert was the chosen theory for this educational project because integrating TL strategies can be considered as a form of skill acquisition. The ongoing development of CNs could be explained by the five stages of skill acquisition. These are: (1) novice, (2) advanced beginner, (3) competent, (4) proficient, and (5) expert (Benner, 1984). Regardless of how long one has been a nurse, the development of the CN as a frontline leader and understanding regarding importance and benefits of integrating TL strategies is best explained by movement of the CN through the five stages. Benner posited experience-based skill acquisition is best suited when based on a sound educational base (Benner, 1984). The goal of the educational project was to promote the importance and benefits of integrating TL strategies
(the sound educational base) with the intent clinical scenarios will add to their experience
(experience-based skill acquisition) and gradually allow progression from novice to expert.
Literature Synopsis
The literature review has revealed CNs are not considered formal leaders and therefore, lack education, training, and mentorship to take on the clinical and administrative duties they are tasked with during their shifts. CNs deal with issues including but not limited to conflict resolution, patient care delivery and meeting organizational needs. This results in meeting competing demands and can lead to ineffective leadership. Most of CN training occurs on the job and ongoing education and leadership training is limited or non-existent. Many of the studies in this project highlighted the importance of ongoing education and mentorship of CNs towards their development as leaders.
Without leadership training, CNs cannot grow as frontline leaders and integrate TL strategies, and this has been shown to negatively impact patient care outcomes and impact job satisfaction and retention rates. The CN is the most accessible and present leader at the bedside and frontline. CNs spend their entire shifts managing competing demands, while providing undertaking patient assignments in most cases. This contributes to role ambiguity and is a barrier to undertaking TL strategies to be effective leaders. Therefore, their ability to effectively lead and communicate within their units and organizations is compromised. This is a matter that requires due attention towards addressing deficiencies within the current healthcare system and building stronger frontline leaders in the future.
The nursing landscape is undergoing significant changes with record number of nurses leaving the profession due to burnout and the current global pandemic. Skill development in communication is a strategy to contribute to the leadership capabilities of CNs. Providing them with necessary skills such as communication is central to their leadership development and ability to do their jobs. When they are provided the tools to succeed and work within an environment that is empowering, this increases job satisfaction and retention of CNs and those that work with them.
Significance and Justification
Findings from the initial literature review revealed a lack of knowledge exists in nursing and patient care practice regarding the leadership development of CNs and subsequently integration of TL strategies in their roles. Most of the literature focused on leadership of managers and directors and failed to consider the critical role CNs play to the 24/7 operation of their units. This was supported by Bateman and King (2020) and Dols et al. (2021) identifying CNs as integral to the running of units, coordination of patient care and communication among care teams within the department and across the organization. CNs act as advocates for patients, colleagues, and their work environments and act as a support and resource to staff and patients (Doherty et al., 2021). CNs are well-equipped to integrate TL strategies in their role as frontline leaders. Boamah et al. (2018) found TL had a significant positive direct effect on structural empowerment and this encouraged bedside clinical leadership practices. This in turn had a positive effect on job satisfaction and a direct negative influence on adverse outcomes (Boamah et al., 2018). CNs are the main point of contact for staff with immediate patient care concerns and thus, should integrate TL strategies in their role as frontline leaders. Therefore, the purpose of this project was significant since it had potential to positively impact leadership development of CNs through integration of TL strategies and as a result, lead to more confident and effective frontline leaders. Furthermore, the lack of literature on CN leadership development is a clear indication for the development of this project as it will allow for further research on the role of
CNs within the healthcare system.
Project Objectives
The objectives of this project were to:
1. Conduct an extensive review of the literature exploring the importance and benefits of integrating transformational leadership strategies for charge nurses using the following keywords both singularly and in multiple combinations: charge nurse, transformational, leadership, front line, nursing, and leader. With the exception of classical works, databases searched, limited to the years 2017 to 2022, included CINAHL complete, Journals@OVID, ScienceDirect, Supplemental Index, PubMed, Gale
Academic OneFile, and Gale General OneFile:
2. Develop an educational training program; and
3. Have a panel of five content experts with extensive knowledge and expertise in recognizing the importance of integrating transformational leadership for charge nurses evaluate and critique the project for clarity, readability, applicability, quality, organization, and evidence-based clinical relevance.
Definition of Terms
The following concepts were defined both theoretically and operationally for the purpose
of this project:
Transformational Leadership
Theoretical Definition: “Leaders…who can serve as full partners with other health professionals and be accountable for their own contributions to delivering high-quality care while working collaboratively with leaders from other health professions” (Institute of Medicine,
2011, p. 221).
Operational Definition: Leadership where charge nurses work towards gaining knowledge and experience to become effective leaders to support development and growth of themselves and others to meet organizational objectives and advocate for positive change for staff, patients, families, and the organization.
Frontline Leader
Theoretical Definition: “Frontline…leaders direct staff and unit systems while ensuring that quality, safe patient care is provided” (McGarity et al., 2020, p. 1). Frontline leaders refers to nurse managers.
Operational Definition: The frontline leader refers to the charge nurse because they are consistently present at the position of care delivery and support staff. They make and influence decisions to coordinate patient care, staffing considerations and manage the flow of the unit.
Limitations
The Project Author recognized the following project limitations:
1. The implementation of the educational training program was not within the context of this project;
2. The educational training program was developed in the English language only and may benefit a more culturally diverse population if written in additional languages;
Project Development Plan
A detailed topical outline of the educational training program content was created based on the extensive review of evidence-based literature and the theoretical framework used to support and guide the development of the educational training program. After permission was granted from the D’Youville Patricia H. Garman School of Nursing, graduate faculty designee (Appendix A), five professionals with knowledge and expertise in recognizing the importance of integrating transformational leadership for charge nurses in a pediatric emergency department were asked if they were interested in voluntarily participating as an expert content reviewer for the educational training program. The content expert panel consisted of three pediatric emergency room charge nurses, one nurse manager, and one hospital administrator. If interested, the Project Author mailed a packet containing a Letter of Intent (Appendix B), a copy of the Content Expert Project Evaluation Tool created by the Project Author specifically for the project (Appendix C), a copy of the educational training program (Appendix D), and a self-addressed stamped envelope. The Letter of Intent explained the project purpose and the instructions for completing and returning the Content Expert Project Evaluation Tool to the Project Author. The Content Expert Project Evaluation Tool contained six evaluative items with space for narrative comments and suggestions. Approximately 20 minutes were required to review the educational training program and to complete the Content Expert Project Evaluation Tool. Content experts were provided a self-addressed envelope to return the Content Expert Project Evaluation Tool to the Project Author. Once all evaluation tools were returned to the Project Author, data were analyzed and reported narratively and in bar graph format. A summary of the evaluation results including the findings of the six evaluative items in the content expert project evaluation tools were provided to the content expert reviewers by postal mail.
Plan for the Protection of Human Subjects
Following approval from the D’Youville Patricia H. Garman School of Nursing, graduate faculty designee (Appendix A), five professionals with knowledge and expertise in the area/field of recognizing the importance of integrating transformational leadership for charge nurses were personally approached and asked to voluntarily participate as a content expert in the review and evaluation of the educational training program (Appendix D). Content experts were advised that participation or non-participation as an expert reviewer will have no effect on their employment status. The Project Author had a collegial, professional, and non-supervisory relationship with the content expert reviewers thereby protecting the participants from any risk of coercion. Content experts were guaranteed confidentiality because identifying characteristics would not be collected on the Content Expert Project Evaluation Tool and because their names would not be revealed anywhere in the project manuscript or in required project presentations. Only the Project Author would know the names of the content expert reviewers. Return of the completed content expert Project Evaluation Tool (Appendix C) would indicate implied voluntary consent to participate as a content expert reviewer. Content experts were advised that they will not be able to withdraw from project participation once the project evaluation tool is returned to the
Project Author because the evaluation tool would be returned without identifying information.
Returned Content Expert Project Evaluation Tools will be stored according to the D’Youville
Patricia H. Garman School of Nursing protocol in a locked drawer located in the Project
Author’s home for a period of six years and then destroyed.
Plan for Project Evaluation
After obtaining full approval from the D’Youville Patricia H. Garman School of Nursing (Appendix A), the Project Author mailed a packet to each content expert reviewer containing one Letter of Intent (Appendix B), one copy of the Content Expert Project Evaluation Tool (Appendix C), one copy of the (product) (Appendix D), and one self-addressed stamped envelope. The Letter of Intent explained the project purpose and instructions for completing and returning the Content Expert Project Evaluation Tool to the Project Author.
The Content Expert Project Evaluation Tool consisted of six evaluative items scored on a four-point Likert Scale that ranges from (1) Strongly Disagree, (2) Disagree, (3) Agree, and (4) Strongly Agree. Space was provided for narrative comments and suggestions following each evaluative item. Evaluative items asked reviewers to rate the educational training program on clarity, readability, applicability, quality, organization, and evidence-based clinical relevance. Approximately 20 minutes were required to review the educational training program and to complete the Content Expert Project Evaluation Tool. Content experts were given seven days to complete and return the Content Expert Project Evaluation Tool to the Project Author via postal mail using the self-addressed stamped envelope included in the original packet. Likert scale responses were presented narratively and displayed in bar graph format. Content expert suggestions and comments were analyzed for common themes and presented narratively. A summary of the evaluation results including the findings of the six evaluative items in the content expert project evaluation tool were provided to the content expert reviewers by postal mail.
Summary
Chapter I presented the project introduction, statement of purpose, an overview of the theoretical framework guiding project development, an initial review of the literature focusing on an educational training program for charge nurses working in an emergency department of a pediatric hospital to promote understanding regarding the importance and benefits of integrating transformational leadership strategies in their role as frontline leaders, the project significance and justification, project objectives, definition of terms, project limitations, the project development plan, the protection of human subjects, the plan for project evaluation, and a chapter summary. Chapter II will provide an extensive review of the literature focusing on an educational training program for charge nurses working in an emergency department of a pediatric hospital to promote understanding regarding the importance and benefits of integrating transformational leadership strategies in their role as frontline leaders and a chapter summary. Chapter III will discuss the intended project setting and population, the content expert participants, data collection methods, project tools, the protection of human subjects, and a chapter summary. Chapter IV will discuss the evaluation of the project, implications for future advanced nursing practice, recommendations for future projects and research, and a chapter summary.
Review of the Literature
A review of nursing and health related literature was conducted to explore the importance and benefits of integrating TL strategies for CNs in their role as frontline leaders using the following keywords both singularly and in multiple combinations: charge nurse, transformational, leadership, front line, nursing, and leader. With the exception of classical works, databases searched, limited to the years 2017 to 2022, included CINAHL complete, Journals@OVID, ScienceDirect, Supplemental Index, PubMed, Gale Academic OneFile, and Gale General OneFile. The search was limited to the years 2017 to 2022 to ensure that current evidence-based literature was reviewed and summarized for the purpose of this project. A summary of the review of the literature is presented.
CN Roles, Responsibilities and Role Ambiguity
While CNs are part of the nursing leadership team, they are not always viewed as formal leaders (Weaver et al., 2018). Different organizations have varying structures in place for the CN role. Some have nurses rotate through the role while others have it as a permanent role among a designated group of nurses on the unit (Spiva et al., 2020). Regardless of the organizational structure, the CN role and responsibilities are poorly defined, leading to role ambiguity. CN responsibilities are often learned on the job and their duties vary in some places depending on the presence of the manager (Andronico et al., 2019; Bateman & King, 2020). Absence of clearly defined CN roles, responsibilities, and expectations to address human resource and management issues when the manager is absent contributes to role ambiguity because the lines between leader and management are blurred (Weaver et al., 2018). Managing staffing, assignments, patient care, patient care coordination, team building, staff performance, conflict management and meeting organizational objectives are some of the CN roles and responsibilities (Bateman & King, 2020; Doherty et al., 2021; Dols et al., 2021; Spiva et al., 2020). Due to the level of responsibility and expectations of the CN, this places a heavy burden on prioritizing competing demands of the unit, staff, patients, and organizational objectives during a shift. This greatly limits their ability to engage in leadership participation, engagement, and building and contributes to a lack of clear leadership and supervision which has been identified as a threat to patient safety (Boamah, 2018; Embree et al., 2018). This is supported by Boettcher et al. (2019) who found most CNs take on unassigned duties during their shifts, adversely impacting their ability to effectively lead. Lack of clear CN roles and responsibilities deprioritizes the leadership impact and capability of CNs. Therefore, protected time to develop leadership skills was mentioned by Jones (2020) as essential to CN development. Protected time allows for CN involvement in committees and conferences (Jones, 2020) contributing to their experiences and growth in TL behaviors. In addition, this takes into consideration the 24/7 nature of CN staffing, promotes investment in the CN role and challenges the view of leadership building as an extracurricular activity (Jones,
2020; Spiva et al. 2020).
Lack of Education, Formalized and Standardized Training and Mentorship Impact on CNs
Many studies have cited the lack of formalized and standardized training of CNs prior to entering and while orienting to the role yields CNs without the proper tools and information to lead (Bateman & King, 2020; Bognar et al., 2021; Doherty et al., 2021; Dols et al., 2021; Laut et al., 2018; Teran & Webb, 2016). Accordingly, Jones (2020) and McGarity et al. (2020) found when CN training occurred well before CNs take on the role and while not actively on the job, this facilitated greater uptake of TL strategies. Correspondingly, Shaughnessy et al. (2018) found a positive correlation between TL practices and higher levels of education. Although CNs do not require advanced degrees for their role, the expectations and responsibilities dictate further education is required. Education and formalized and standardized training can increase the TL strategies, resilience, and confidence of CNs. This is supported by findings by Cariaso-Sugay et al. (2021), Dols et al. (2021), Laut et al. (2018) and Spiva et al. (2020), where training was found to increase resilience among CNs and increase their confidence in the role. It is important to consider the importance and value of protected time to be available to CNs to further develop TL skills after entering the role. Jones (2020) and McGarity et al. (2020) reinforced the value of protected time for CN leadership skills development and deemed it essential. Education for CNs must go beyond focus on the task they are expected to complete on their shift. CNs require formalized and standardized training and education on communication, conflict management, managing staff performance and TL strategies to meet demands of their role and objectives of the organization in which they work. CNs are considered expert clinicians and possess foundational leadership skills (Bateman & King, 2020; Boettcher et al., 2019). When they become CNs, they are considered novice; therefore, they need education, training, and mentorship to facilitate their success (Boettcher et al., 2021; Bognar et al., 2021; Doherty et al., 2021; Teran & Webb, 2016). It cannot be stressed enough the importance of ongoing development of CNs and the positive impact it can have on staff, patients, and the organization. Boettcher et al. (2019) and Dols et al. (2021) found mentorship and preceptorship by CNs was found to have a positive impact on nursing-sensitive indicators and improved workflows leading to higher levels of patient care.
Effects of TL by CNs on Patient Care Outcomes and Structural Empowerment
TL has been associated with reduced incidences of adverse patient events because it creates environments where professional nursing practice is supported and promotes better patient outcomes (Boamah, 2018; Boamah et al., 2018; Hudson-Covolo et al., 2018; Teran &
Webb, 2016). Additionally, TL among CNs can improve patient engagement (McGarity et al., 2020) through behaviors such as patient rounding which was found to lead to positive patient outcomes (Hudson-Covolo et al., 2018; Kramer & Davies, 2021). CN TL development has potential to positively impact organizations to deliver high-quality patient care to a growingly complex patient population. Current healthcare systems are disintegrating from demands prior to and during the pandemic. Therefore, TL strategies among CNs is needed to ensure patient care is not impacted and staff are in healthy work environments. Likewise, healthy work environments are achieved when CNs can function in settings that do not hinder their ability to lead (Boamah, 2018). Supportive work environments with policies in place to protect patients and staff safety, functioning medical technology and conducive workflow designs are just some examples of structural empowerment resulting from TL strategies among CNs (Boettcher et al., 2019). As a result, structural empowerment through TL can increase CN confidence in their role to positively impact their teams and organization as reported by Boamah (2018), Cariaso-Sugay et al. (2021), Dols et al. (2021) and Kramer & Davies (2021). TL strategies were found to increase uptake of lean methodology in a study by Boettcher et al. (2019) and subsequently increased CN engagement. The experience and breadth of knowledge of CNs ensures efficient unit flow and operations. Enhancing the CN role through TL strategy integration would support positive patient outcomes, structural empowerment and has potential to positively impact the healthcare system.
CN Influence on Nurse Retention and Job Satisfaction
The projected nursing shortage in Canada and the United States is a cause for concern for many health policy advocates, government critics and unions. The ongoing COVID-19 global pandemic has only exacerbated this issue with growing concern regarding nurse staffing affecting ability of organizations to provide and deliver care safely. Policy makers are at a crucial junction and nurse retention is paramount to a sustainable healthcare system. Studies by AlMajid et al. (2018), Bognar et al. (2021), Dols et al. (2021), Sisk et al. (2021) and Teran and Webb (2016) found CN development within organizations positively impacted nursing retention rates. Particularly, Bognar et al. (2021) found CN mentorship helped with nursing retention. There are many factors causing nurses to leave the workplace and the effect of nursing leadership has been identified as a reason. A study by Laut et al. (2018) identified the effect of the CN on others and lack of support as a factor for new nurses to leave the emergency department. The importance of the CN role was considered by senior nursing leaders in one organization and as a result, a supportive CN model was implemented to specifically address retention (Sisk et al., 2021). Boettcher et al. (2019) and Laut et al. (2021) found positive CN behaviors decreased staff turnover; specifically, among new nurses. In addition to nurse retention, CNs increase job satisfaction in their work environments. It was previously discussed how CN TL positively influences structural empowerment. Positive workspaces lead to job satisfaction among CNs and colleagues as reported by Bognar et al. (2021). CNs work closely with bedside nurses and are involved in patient care coordination of their units. Positive interactions and relationships with colleagues increase perceived levels of support from CNs by staff (Laut et al., 2021). Thus, leading to higher levels of job satisfaction and reduced nursing turnover. Development of TL strategies among CNs enhances their leadership capabilities and has potential to greatly influence nursing retention and job satisfaction among colleagues.
Communication and the CN role
Frontline leaders such as CNs, must possess effective communication skills because they are tasked with coordinating patient care, identifying key issues, and raising awareness amongst senior nursing leaders and managing conflict. Communication is considered essential to the CN role because CNs communicate within their care teams as well as across organizations and is viewed as a trait that makes CNs feel successful (Bateman & King, 2020; Doherty et al., 2021; Embree et al., 2018; Spiva et al., 2020; Teran & Webb, 2016). Communication is a skill requiring ongoing development as noted by Doherty et al., (2021) who found communication to be a challenging area for CNs the longer they remained in the role. In the studies reviewed for this project, simulation, in-class lectures, and online resources were implemented as strategies to enhance development of communication skills for CNs (Bateman & King, 2020; Doherty et al., 2021; Spiva et al., 2020; Teran & Webb, 2016).
Impact of Secondary Traumatic Stress, Compassion Fatigue, Burnout and Resilience on
CNs
As frontline leaders, CNs endure stress from their role, colleagues, and patients. If stress is not effectively managed, this puts CNs at risk for compassion fatigue (CF), secondary traumatic stress (STS) and burnout (Al-Majid et al., 2018). In a study by Kramer and Davies (2021), managing role-related and staff stress was identified as a challenge by CNs. Inability to manage stress affects CN resilience and adversely impacts those around them and their ability to lead. Strategies to address CF, STS and burnout are needed in this group so they can empower staff through TL strategies to deliver high-quality patient care. Therefore, training and education on resilience is needed. A study by Spiva et al. (2020) found higher rates of resilience among CNs after participation in a training program. This supports the need for ongoing recognition, training, and development in CF, STS, and burnout in CNs to ensure experienced leaders are introduced and remain in the role. It is noteworthy, burnout, CF and STS are not limited to novice CNs. Interestingly, a study by Doherty et al. (2021) found the longer CNs stayed in the role, levels of stress grew, and this was associated with level of responsibility expected of them but lack of authority to execute these duties. In the same study, it was found CN confidence to perform increased the longer they stayed in the role (Doherty et al. 2021). This is evident longevity in the CN role requires greater focus on leadership capabilities over task performance. Role confidence alone is not enough because it fails to highlight need for long-term TL development in CNs. Due attention must be paid to occupational hazards of CNs to ensure adequate supports are in place to address CF, STS, and burnout for them to be effective leaders.
Summary
Chapter II presented a review of nursing and health related literature exploring the importance and benefits of integrating TL strategies for CNs in their role as frontline leaders. Chapter III will discuss the intended project setting and population, the content expert participants, data collection methods, project tools, the protection of human subjects, and a chapter summary. Chapter IV will discuss the evaluation of the project, implications for future advanced nursing practice, recommendations for future projects and research, and a chapter summary.
CHAPTER III
PROJECT DEVELOPMENT PLAN
Chapter III will discuss the intended project setting and population, the content expert participants, data collection methods, project tools, the protection of human subjects, and a chapter summary.
Project Setting and Population
The intended project setting was the emergency department of a pediatric hospital. The intended project population were charge nurses in the emergency department of a pediatric hospital.
Content Expert Participants
Following approval from D’Youville Patricia H. Garman School of Nursing (Appendix A), five content experts with knowledge and expertise in the role of the charge nurse were contacted by the project author and asked to voluntarily participate in the review of the project for clarity, readability, applicability, quality, organization, and evidence-based clinical relevance. The first content expert was a charge nurse in a pediatric emergency department with over 10 years of nursing experience and is currently pursuing a master’s degree in nursing. The second content expert was a charge nurse in a pediatric emergency department with over 10 years of nursing experience and is currently pursuing a master’s degree in nursing. The third content expert was a charge nurse in a pediatric emergency department with over 20 years of nursing experience that includes research, critical care nursing experience and is an instructor for a pediatric emergency nursing course. The fourth content expert was a master’s prepared nurse manager with previous experience as an emergency room charge nurse. The fifth content expert was a hospital administrator with a master’s degree in nursing with previous experience as nurse
manager and director.
Data Collection Methods
The educational training program was developed based on an extensive review of the literature. The student has not developed the educational training program based on feedback from the content experts. The student develops the product and then asks for feedback. Upon receipt of full approval from D’Youville’s Patricia H. Garman School of Nursing (Appendix A), the five content experts were contacted by the Project Author and asked to voluntarily participate in the review and evaluation of the educational training program. All five content experts agreed to participate. A manila envelope containing a recruitment Letter of Interest (Appendix B), one copy of the Content Expert Project Evaluation Tool (Appendix C), one copy of the educational training program (Appendix D), and a stamped self-addressed envelope with instructions on how and when to return the evaluation tool to the Project Author was provided. Content experts were asked to review and evaluate the educational training program for clarity, readability, applicability, quality, organization, and evidence-based clinical relevance. The content experts were instructed not to place any identifying marks on the evaluation tool. Return of the evaluation tool signified implied consent to participate as content experts. Content experts returned the evaluation tool to the Project Author using a self-addressed stamped envelope.
Project Tools
The purpose of this project was to develop an educational training program (Appendix
D). The development of the educational training program was guided by Benner’s Novice to
Expert theory. The educational training program (Appendix D) consisted of transformational leadership strategies to be incorporated in the charge nurse role developed based on findings obtained from the review of current evidence-based literature.
A Content Expert Evaluation Tool (Appendix C) was developed by the Project Author specifically for the purpose of having five content experts with knowledge and expertise in the charge nurse role to evaluate the educational training program on clarity, readability, applicability, quality, organization, and evidence-based clinical relevance. The content experts were asked to rate the six evaluative items using the following four-point Likert Scale: Strongly Disagree (1), Disagree (2), Agree (3), and Strongly Agree (4). The content experts were instructed to circle one response for each item indicating their appraisal for that particular item. Space was made available immediately following each evaluative item to provide the content experts with opportunity to comment or make further suggestions if needed. Data from the Content Expert Evaluation Tool were collated, analyzed, and presented in narrative and bar graph format. Content expert written comments and suggestions were analyzed for common themes and presented in narrative format.
The Protection of Human Subjects
Following approval from the D’Youville Patricia H. Garman School of Nursing
(Appendix A), five experts with knowledge and expertise in the charge nurse role and benefits of integrating transformational leadership were approached and personally asked to participate as a content expert reviewer for the educational training program developed for the purpose of this project. The Project Author had a collegial, professional, and non-supervisory relationship with the content expert reviewers thereby protecting the participants from any risk of coercion. The content expert participants were advised that participation or non-participation as a content expert reviewer would have no effect on their employment or evaluative status. The participants were guaranteed confidentiality as identifying characteristics would not be displayed on the
Content Expert Evaluation Tool (Appendix C) and all data would be reported in aggregate form. Return of the completed Content Expert Evaluation Tool would indicate implied consent to participate as a content expert. All five content experts were advised that their participation was completely voluntary and that they would not be able to withdraw from project participation once the completed Content Expert Evaluation Tool was returned to the Project Author as there would be no way to identify them. Returned Content Expert Evaluation Forms will be kept in a locked file cabinet drawer located in the Project Author’s home for a period of six years and then destroyed as per IRB protocol.
Summary
Chapter III discussed the intended project setting and population, a detailed description of the content expert participants, data collection methods, project tools, the protection of human subjects, and a chapter summary. Chapter IV will discuss the evaluation of the project, implications for future practice, and recommendations for future projects and research.
CHAPTER IV
PROJECT EVALUATION, IMPLICATIONS, AND FUTURE RECOMMENDATIONS
Chapter IV will discuss the evaluation of the project, implications for future practice, and recommendations for future projects and research.
Project Evaluation
After permission was obtained from the D’Youville Patricia H. Garman School of Nursing (Appendix A), five content experts with knowledge and expertise in the benefits of integrating transformational leadership in the charge nurse role were approached in person and asked to voluntarily review and evaluate the educational training program using a Content Expert Evaluation Tool developed by the Project Author. The Content Expert Evaluation Tool included six items asking content experts to evaluate the educational training program on clarity, readability, applicability, quality, organization, and evidence-based clinical relevance. The content experts were asked to rate the six evaluative items using the following four-point Likert Scale: Strongly Disagree (1), Disagree (2), Agree (3), and Strongly Agree (4). Space was made available immediately following each item to provide the content experts with opportunity to comment or make further suggestions if needed. Following is a discussion of the results of the content expert evaluation.
The first question on the Content Expert Evaluation Tool asked the content experts if they felt that the questions presented on the educational training program were clear and comprehensible. Three out of the five content experts (60%) agreed that the questions were clear and comprehensible, and one content expert (20%) strongly agree. One content expert (20%) strongly disagreed that the questions were clear and comprehensible.
Question two on the Content Expert Evaluation Tool asked the content experts if they felt that the questions included on the educational training program were presented at an appropriate level of reading for charge nurses. Two out of the five content experts (40%) strongly agreed that the questions were presented at an appropriate level of reading for the intended population and two content experts (40%) agreed. One content expert (20%) disagreed that the questions were presented at an appropriate level of reading for the intended population.
Question three on the Content Expert Evaluation Tool asked the content experts if they felt that the questions included on the educational training program were relevant and fits the project purpose. Three out of the five content experts (60%) strongly agreed that the questions were relevant and fits the project purpose. Two content experts (40%) disagreed that the questions were relevant and fits the project purpose.
Question four on the Content Expert Evaluation Tool asked the content experts if they felt the educational training program is well designed and professionally presented. Three out of the five content experts (60%) agreed the educational training program is well designed and professional presented. Two content experts (40%) disagreed the educational training program is well designed and professional presented.
Question five on the Content Expert Evaluation Tool asked the content experts if they felt the educational training program is logical and well organized. Three out of the five content experts (60%) agreed the educational training program is logical and well organized and two content experts (40%) strongly agreed.
Question six on the Content Expert Evaluation Tool asked the content experts if they felt the educational training program addresses a current and clinically relevant problem in nursing and patient care practice and utilizes current clinical evidence. Four out of the five content experts (80%) strongly agreed the educational training program addresses a current and clinically relevant problem in nursing and patient care practice and utilizes current clinical evidence and one content expert (20%) agreed with this question.
Written comments and suggestions given by the content experts to strengthen the development of the educational training program are summarized as follows with examples. Four content experts commented on the implementation of the educational training program. One content expert wrote “It needs more information on how this can be implemented, how we would actually use the tool. I think it is the training side that needs more depth. It needs some tailoring to be more direct, give some examples and fine tune the teaching portion”. Another content expert wrote, “…The notion of a package to allow for individuals to perform self-reflection is valid for self-awareness and understanding of one's ways of improving, however as seen in the definition of training, to me as a reviewer does not meet criteria. My initial thought was to receive some type of teaching/learning component (Via, lecture, Zoom Meeting, class, educational link…) to have and expert present, and teach transformation a leadership components, with the implementation of using a theoretical framework (Benner's Novice to
Expert)…”. A third content expert wrote, “Having the learners perform the same assignment four times is repetitive and the learner may become disengaged and the value in why there are doing it, which is reflecting on their practice, may be lost. (I am not appreciating why this assignment is occurring four times and what type of time frame it is occurring.)”. A fourth content expert wrote. “What happens after all of the examples have been entered? Where does the CN go from there? Is there any follow up?”. The comments of four out of five content experts suggest more clarity on the delivery and implementation of this educational training program is required.
Furthermore, clarifying the purpose and overall goal of the project, setting objectives for participants and providing follow-up are methods to be considered to enhance implementation of the project.
All the content experts commented on the use of transformational leadership in the educational training program and whether clarity is needed for learners of the educational training program. One content expert wrote, “If CNs are pulling from Novice/Advanced Beginner examples, they may not yet possess Transformational Leadership qualities that can be applied to the example. Maybe the first question could be, Which component(s) of TL (if any) is demonstrated in your example?” A second content expert wrote, “The training program is a little abstract, I think having some examples or areas written in your own words might be more helpful. It also depends on the level/years of experience as a leader because younger leaders may not have the experience to reflect on all of these scenarios”. A third content expert wrote, “Possibly providing example of each of the Transformational Leadership styles along with the definition provided. For some learners this may be the first time they are learning about transformation (sic) leadership as well one tries to find themselves in these theoretical models in order for them to understand how this new knowledge relates to them.” A fourth content expert wrote, “The explanations of TL might include an easy to read summary at the beginning or end of the quotes. Your participants might find the quotes lengthy and have difficulty pulling the most important points out of them. Of course, this would depend on how engaged your audience is. The less engaged individuals are going to need things in simple, easy to read format that they can refer to multiple times.” A fifth content expert wrote, “Have quite a number of concerns in the implementation of a self-taught development, educational, and training program of this very broad concept. Transformation a leadership, is an extremely vast, varying methods, and evolving concept to be a self-taught educational package in the expectation of self-training/selfdevelopment and self-learning. (Especially when your audience varies from novice -to expert).” All the content experts discussed the need for examples of transformational leadership in the educational training program. Concern for first time learners not familiar with transformational leadership or those with limited to no experience and their ability to apply transformational leadership was raised. Inclusion of examples, possibly at each stage of Benner’s theory would
allow for increased clarity and understanding for learners at different stages.
Three of the content experts commented on the use of reflective practice in the educational training program. One content expert wrote, “I think the reflective approach is a good one to take, which will allow for charge nurses to learn from previous experiences they have had. I wonder if the last question might be more explicit and ask them what they learned from the experience and what they might do differently next time?”. A second content expert wrote, “I see that we are drawing from our own experiences to tie transformational leadership to our current practice, and while the key terms and theory are useful to understand I think there could be a bit more direction to the training program.” A third content expert wrote, “You might expand further on this instruction: “You will write down examples in the space provided that stand out to you in your leadership as a CN and answer the corresponding questions”.
Suggestions: Begin the instructions by asking the reader to reflect on various scenarios they have experienced as a CN and to provide an example of how TL was incorporated. You might also include what exactly will be required of the CN in the introduction. For example adding: ‘to promote understanding through reflective practice.’ Or something of the sort.” The comments of three out of five content experts supports the use of reflective practice in the delivery of the educational training program in conjunction with further instruction and direction relating to the educational training program and expectations of the learner of the training program.
Two of the content experts commented on the use of Benner’s theory in the educational training program. One content expert wrote, “The reason for choosing Benner’s Theoretical model versus others might be worth mentioning briefly so the learner understands why this particular models suites (sic) or achieves the learning objectives you are striving for.” A second content expert wrote, “Use of Benner’s theory as an expectation for all Nursing professionals is great as there is an expectation that all nurses are aware of this theoretical concept.-great!” The comments of two out of five content experts supports the use of Benner’s theory. It is worth considering providing rationale to the learner on selecting Benner’s theory for the educational training program.
Two of the content experts commented on the need to enhance leadership in nursing roles. Once content expert wrote, “Agree, there is a strong need to enhance leadership understanding/learnings, especially toward the CN’s in the ED depts of any hospital. As we know in the CN in an ED are the forefront for Staff and pt/families and equally the face of the Ed dept as a leader.” A second content expert wrote, “Certainly having people in informal (and formal) leadership roles who do not have an understanding of leadership styles is not ideal. Ideally all leaders undergo formal leadership style education. But this is not feasible. It can also be difficult to teach leaders about leadership styles without enrolling them in a formal course. This is related to amount of engagement and time required for each person to gain a true understanding of the topic.” The comments of two out of five content experts suggest the importance for enhancement of leadership in nursing roles. Consideration of staff engagement and feasibility as one content expert suggested is important when promoting understanding and the benefits of integrating transformational leadership strategies.
Implications for Future Nursing Practice
This project highlighted the need for consideration of enhancing leadership of informal nursing roles such as that of the charge nurse. Education and ongoing professional development through combination of didactic modalities, use of reflective practice and mentorship relationships are strategies to promote understanding and benefits of integrating transformational leadership strategies amongst charge nurses. This would require mobilization and support of senior and executive leaderships within an organization. Initial and ongoing investment in leadership education of informal leaders such as charge nurses is prudent to the sustainability of healthcare institutions and the healthcare system. Without investment into leadership education of charge nurses, health care organizations risk losing nursing staff. Studies by Al-Majid et al. (2018), Bognar et al. (2021), Dols et al. (2021), Sisk et al. (2021) and Teran and Webb (2016) found CN development within organizations positively impacted nursing retention rates. At a time, where a global pandemic has and continues to burnout large numbers of nurses, all solutions to enhance work environments must be considered. Bognar et al. (2021) reported positive workspaces led to job satisfaction among CNs and colleagues. To address long-standing issues within healthcare systems, organizations must prioritize leadership training of charge nurses within their organizations as they are the frontline leaders continually interacting with staff, patients, and families and have the potential to positively impact organizations and the healthcare system.
Future Recommendations
The purpose and intention of this project was to address a current gap in nursing and health related knowledge regarding the educational needs of charge nurses. Future projects and research should focus on exploring and examining barriers to implementing leadership training for charge nurses. Furthermore, future research and projects should focus on the cost/benefit analysis of leadership training for charge nurses. In addition, effects on patient outcomes, staff engagement, workplace culture are also areas of focus to be considered in future research and projects. Finally, Benner’s (1984) theory fit well as a theoretical framework to support the development of the educational training program and should be considered as a theoretical framework to support future projects and research related to patient care practice in this particular area of interest.
Summary
In summary, the purpose of this project was to promote understanding and the benefits of integrating transformational leadership strategies for charge nurses in a pediatric emergency room through use of an educational training program. Chapter I presented the project introduction, statement of purpose, an overview of the theoretical framework guiding project development, an initial review of the literature focusing on an educational training program for charge nurses working in an emergency department of a pediatric hospital to promote understanding regarding the importance and benefits of integrating transformational leadership strategies in their role as frontline leaders, the project significance and justification, project objectives, definition of terms, project limitations, the project development plan, the protection of human subjects, the plan for project evaluation, and a chapter summary. Chapter II presented a review of nursing and health related literature exploring the importance and benefits of integrating TL strategies for CNs in their role as frontline leaders. Chapter III discussed the intended project setting and population, a detailed description of the content expert participants, data collection methods, project tools, the protection of human subjects, and a chapter summary.
Chapter IV discussed the evaluation of the project; including a summary of content experts to strengthen the development of the educational training program, implications for future practice, and recommendations for future projects and research.
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Appendix
A
Patricia H. Garman School of Nursing
Full Approval Letter
320 Porter Avenue
Buffalo, New York 14201-1084
TO: Huda Sherif
FROM: Graduate Faculty, Patricia H. Garman School of Nursing
DATE: February 2, 2022
SUBJECT: Full Project Approval
I am pleased to inform you that your application to the Patricia H. Garman School of Nursing entitled:
“An Educational Training Program for Charge Nurses on Promoting Understanding and the Benefits of Integrating Transformational Leadership Strategies.” has been granted FULL APPROVAL. This means that you may now begin your research unless you must first apply to the IRB at the institution where you plan to conduct the research.
Congratulations and good luck on your research!
Dr. Christine Nelson-Tuttle
cc: Student
School of Nursing
Appendix
B
Letter of Intent
Content Expert Letter of Intent
Dear Content Expert,
Hello, my name is Huda Sherif. I am a graduate student completing a Master of Science in Nursing Management and Quality Leadership degree at D’Youville College in Buffalo, New York. Currently, I am developing an educational training program for charge nurses working in an emergency department of a pediatric hospital to promote understanding regarding the importance and benefits of integrating transformational leadership strategies in their role as frontline leaders. I am submitting the educational training program for your expert review and evaluation. Recommendations and critique of this work in progress will be taken into serious consideration during the final revisions of this work.
You are being asked to review and evaluate the educational training program for clarity, readability, applicability, quality, organization, and evidence-based relevance. Your review of the educational training program should take approximately 20 minutes of your time. The evaluation process is completely voluntary and your refusal to participate will involve no penalty or loss to you. Your responses will be kept confidential and will be available only to me. If you choose to participate, please return the evaluation tool within the next seven (7) days using the enclosed self-addressed stamped envelope. Consent to participate in the evaluation is implied upon the completion and return of the evaluation tool. Once you return the evaluation tool, there is no way to withdraw your responses, as there are no identifying markers included on the tool. Returned evaluation tools will be stored in a locked drawer in my home for a period of six years and then destroyed. There are no direct benefits to you as a content expert participant. A copy of the results including the findings of the six evaluative items in the content expert project evaluation tool will be mailed to you at the conclusion of this project.
If you have any questions regarding my project or the evaluation process, please contact me via email at [email protected]. Any specific questions may be directed to Dr. Sharon Mang, my Project Chair, at (716) 829-8376 or via email at [email protected]. Thank you for your assistance and participation as a content expert. I look forward to receiving your evaluation of my project.
Best Regards,
Huda Sherif
Appendix
C
Evaluation Tool
Instructions: The purpose of this tool is to provide you with a guideline for evaluating the clarity, readability, applicability, quality, organization, and relevance to current evidencebased practice of the proposed educational training program. The purpose of this project is to develop an educational training program for charge nurses working in an emergency department of a pediatric hospital to promote understanding regarding the importance and benefits of integrating transformational leadership strategies in their role as frontline leaders. Using the four-point Likert Scale, please circle one choice that best reflects your opinion. Space is provided after each of the six evaluative items for further feedback and direction regarding the educational training program. To maintain your confidentiality, please do not make any identifying marks on the evaluation tool.
Clarity
The information presented in the educational training program is clearly understood and easy to follow.
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Readability
The information in the educational training program is presented at an appropriate and comprehensive level of reading for charge nurses.
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Applicability
The information presented in the educational training program is relevant and fits the project purpose.
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Quality
The educational training program is well designed and professionally presented.
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Organization
The educational training program is logical in order and well organized.
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Evidence-Based Clinical Relevance
The educational training program addresses a current and clinically relevant problem in nursing and patient care practice and utilizes current clinical evidence.
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Thank you for taking time to evaluate the educational training program. Your feedback is deeply appreciated and will strengthen the development of the educational training program.
Appendix
D
Educational Training Program
AN EDUCATIONAL TRAINING PROGRAM FOR CHARGE
NURSES ON PROMOTING UNDERSTANDING AND THE
BENEFITS OF INTEGRATING TRANSFORMATIONAL
LEADERSHIP STRATEGIES
BY: HUDA SHERIF RN, BSCN D’YOUVILLE COLLEGE
NOTE: Changes to the educational training program were made based on feedback from the content experts.
Introduction
The charge nurse (CN) is the frontline leader in most healthcare settings and is the most accessible to nursing and interdisciplinary staff on shift in addressing clinical and administrative concerns. The CN is a frontline leader who often receives little to no initial training and lacks ongoing professional and leadership development. Transformational leadership (TL) is an approach where leadership capacity of others is developed, inspires team members to achieve great results and places emphasis on a value system. As frontline leaders, CNs are well equipped to embrace TL strategies because of their background as clinicians and experience as frontline leaders. The purpose of the educational training program is to promote understanding and the benefits of integrating TL strategies in the CN role, as it has potential to positively impact healthcare delivery.
To familiarize the learner with transformational leadership, definitions of its four major components is provided below with clinical examples to aid the user of this program. In addition, Benner’s Novice to Expert was utilized as the theoretical framework for this program. A brief explanation of Benner’s theory and its relation to TL strategies is provided.
Transformational Leadership
The components of transformational leadership and their definitions are provided below:
1. Idealized influence: “The person with charisma of idealized influence finds effectiveness stemming from a strong belief in others. Charisma is the ability to influence others, to inspire not only a willingness to follow, but also an expectation of success, an anticipation of becoming part of something greater than self. Charismatic leaders know who they are and where the organizational unit they are leading has the potential to go.” (Broome & Marshall, 2021, p.16).
Definition of idealized influence as it relates to the CN: As a CN, you believe in the potential of your team. You take calculated risks and allow for discussion with your team so they can understand your decision-making and agree to participate in your direction for the team. You make it clear that this decision is being made because the team possesses the skills to succeed.
Example: In the emergency department, there is an admitted psych patient. The patient will be sent to another unit due to no bed availability on the psychiatric ward. The patient has a security watch and the nurses caring for the patient are telling you as the CN, they have tried to give report to the unit receiving this patient, but they are not taking this patient. You speak with the CN of the receiving unit and the CN expresses concern about certain findings in the patient chart that have yet to be addressed. The receiving unit has high acuity on their ward. They are willing to take the patient but would like for admitting MD to assess the patient before taking report. You agree with their decision and communicate this with your team. ER nurses are not happy with this plan. They feel that since this patient has bed on the ward, they should go up instead of taking up a bed here. You explain the ward will take the nurse but need some time. You explain at this time, we can support care for this patient down here whereas, if the patient were to go up, it would be unsafe and may not result in the best outcome for this patient. After ongoing discussion, the team agrees with your plan.
2. Inspiration and vision: “Transformational leaders influence others by high expectations with a sight toward the desired future. They set standards and instill others with optimism, a sense of meaning, and commitment to a dream, goal, or cause. They extend a sense of purpose and purposeful meaning that provides the energy to achieve goals. They inspire from a foundation of truth.” (Broome & Marshall, 2021, p. 17).
Definition of inspiration and vision as it relates to the CN: As a CN, you set goals for your team at the start of the shift. You verbalize your expectation of the team and yourself to your team on an ongoing basis.
Example: At the start of your shift as the CN, a nurse who has transitioned into a new role expresses they are apprehensive and how do not feel ready to take on this responsibility. You know this individual has received training and has had some exposure to this new role. You speak with them about their concerns, allow them to express their perceived strengths they bring to this role and what are their perceived weakness. You strategize how the person can optimize their success in this role. You offer them words of encouragement and motivation by stating “I have seen you provide great care to patients and families. I know you have the knowledge, skill, and judgement to care for critically ill patients. I want you to tell yourself that you can do this and know that if you need help that is ok. We are all here together.”
3. Intellectual stimulation: “The transformational leader is a broadly educated, wellinformed individual who looks at old problems in new ways. He or she challenges boundaries, promotes creativity, and applies a range of disciplines, ideas, and approaches to find solutions. This involves fearlessness and risk-taking. The transformational leader in healthcare reads broadly, takes lessons from many disciplines beyond clinical practice, and engages as an interested citizen in public discourse on a full range of topics.…... He or she consults experts from a variety of fields and settings to weigh in on complex problems faced by the organization. Such leaders ask questions. Asking questions about problems, large and small, allows leaders to understand the landscape in which the problem “lives,” and they can pull together teams to work on the problem and encourage, expect, and nurture independent and critical thinking. The transformational leader assumes that people are willing and eager to learn and test new ideas.” (Broome & Marshall, 2021, p.17-18).
Definition of intellectual stimulation as it relates to the CN: As a CN you conduct a risk assessment and are willing to challenge the status quo to better serve patients and staff. You make innovative decisions in the moment and use these as examples to support needed change when communicating with management.
Example: As the CN, you come on to shift to find you only have 1 registration and 1 information clerk when you are supposed to have 1 of each. There is a third individual who is new to the role and not able to support all the functions of the role. The registration clerk, information clerk and you work-out a break plan. There is a three-way break scheduled and because registration is only a priority for resuscitation or trauma patients, the remaining patients can wait to be registered when the clerk returns. In the event of either of those events, the registration clerk would return, if on break to register this patient. Prior to this, the practice was once the patient was triaged, registration would occur. Your solution looks at the current practice and attempts to implement change to support staff and while not compromising patient care.
4. Individual Consideration: “The transformational leader has a kind of humility that looks beyond self to the mission of the organization and the value of the work of others as individuals. He or she uses many professional skills including listening, coaching, empathy, support, and recognition of the contributions of followers. The transformational leader enables others to act toward a shared vision. The effective leader recognizes and promotes the contributions of others and creates a culture of sharing, celebration, and unity within the entire team.…..Transformational leaders effectively build on these characteristics and integrate principles from a variety of leadership theories and pragmatic approaches to advance, enhance, and expand clinical expertise from a focus on direct individual patient care to a focus on the care of groups, aggregates, and entire populations in a variety of environments. They consider the individual and the aggregate at once.” (Broome & Marshall, 2021, p.18).
Definition of individual consideration as it relates to the CN: As a CN, you recognize your team and individual members with their accomplishments. Timely positive feedback provides encouragement to staff to maintain positive behaviors.
Clinical example: Each shift as a CN, you recognize excellence amongst individual staff and teams. You provide words of encouragement and are always willing to listen to staff and provide them with support.
Theoretical Framework
Benner’s Novice to Expert was the chosen theory for this educational training program because it is widely known by nurses and allows for the learner to easily identify their level of skill acquisition regarding decision-making and/or behaviors. The ongoing development of CNs and understanding regarding importance and benefits of incorporating TL strategies can be explained by the five stages of skill acquisition in Benner’s theory. These five stages are as follows: (1) novice, (2) advanced beginner, (3) competent, (4) proficient, and (5) expert (Benner, 1984). Below you will find the definitions for each stage of skill acquisition:
1. Novice: The novice practitioner does not possess previous knowledge or experience to draw from in situations they are expected to practice (Benner, 1984).
2. Advanced beginner: The advanced beginner practitioner begins to apply principles they possess but require assistance of more experienced practitioners to ensure patient needs are met (Benner, 1984). The advanced beginner lacks appreciation of the whole situation and requires assistance in identifying key findings during assessments to ensure safety of patients and themselves as practitioners (Benner, 1984).
3. Competent: The competent practitioner has been in the same or similar situations and is able to plan and prioritize tasks that are to be completed (Benner, 1984). In this stage, the competent practitioner builds on practical and theoretical knowledge. Exposure to past clinical scenarios instills confidence in the competent practitioner to begin applying knowledge gained from previous clinical experiences to make decisions about current situations (Benner, 1984).
4. Proficient: The proficient practitioner perceives situations as a whole, based on previous knowledge and experience (Benner, 1984). Decision-making is easier because they can identify what information being presented is key to long-term planning in care delivery (Benner, 1984). Furthermore, the proficient practitioner can identify subtle information which may go unnoticed by the novice to competent practitioner, aiding in appropriate and timely care delivery (Benner, 1984).
5. Expert: The expert practitioner does not rely on theoretical knowledge to guide decisionmaking; rather, the nurse guides decision-making based on clinical experience and instinct (Benner, 1984). Benner (1984) explained the expert practitioner uses theoretical knowledge when faced with an unfamiliar situation or when their conclusion or actions in a situation were incorrect. During this time of reflection, the expert practitioner can identify errors and find explanation in situations based on previously learned theories.
Instructions
The educational training program will use personal reflection to aid in understanding of transformational leadership components. Reflect on various scenarios you have experienced as a CN to provide an example of how TL was incorporated to promote understanding through reflective practice. For each scenario, consider behaviors, attitudes and/or decisions made when selecting what stage of skill acquisition is best demonstrated in the example. You will then answer the corresponding questions. While answering the following questions, please refer to the definitions for the components of TL and the stages of skill acquisition above.
You may not be able to provide a personal example for each component of transformational leadership. If unable, to provide an example, consider a situation you observed by another CN and how the component of transformational leadership was demonstrated and provide learning points from this example.
To promote ongoing learner and reflection, this exercise will be performed every four months with a goal to go discuss with management the CNs acquisition of TL strategies during yearly performance reviews.
Example of idealized influence:
1. Which component(s) of idealized influence (if any) is demonstrated in the example?
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2. Consider behaviors and/or decisions in this example when answering the following. Which stage of skill acquisition according to Benner’s Novice to Expert is best demonstrated in this example? Please explain why you have chosen that stage of skill acquisition.
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3. What are some learning points to consider from this example in relation to transformational leadership?
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Example of inspiration and vision:
1. Which component(s) of TL (if any) is demonstrated in the example?
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2. Consider behaviors and/or decisions in this example when answering the following. Which stage of skill acquisition according to Benner’s Novice to Expert is best demonstrated in this example? Please explain why you have chosen that stage of skill acquisition.
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3. What are some learning points to consider from this example in relation to transformational leadership?
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Example of intellectual stimulation:
1. Which component(s) of TL (if any) is demonstrated in the example?
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2. Consider behaviors and/or decisions in this example when answering the following. Which stage of skill acquisition according to Benner’s Novice to Expert is best demonstrated in this example? Please explain why you have chosen that stage of skill acquisition.
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3. What are some learning points to consider from the example in relation to transformational leadership?
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Example of individual consideration:
1. Which component(s) of TL (if any) is demonstrated in your example?
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2. Consider behaviors and/or decisions in this example when answering the following. Which stage of skill acquisition according to Benner’s Novice to Expert is best demonstrated in this example? Please explain why you have chosen that stage of skill acquisition.
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3. What are some learning points to consider from this example in relation to transformational leadership?
References
References
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice.
Addison-Wesley.
Broome, M. E., & Marshall, E. S. (2020). Transformational leadership in nursing: From expert clinician to influential leader (3rd ed.). Springer.
Untitled illustration of transformational leadership. (2017). Pixabay.
https://pixabay.com/illustrations/joint-project-management-2161488/
Appendix
E
Survey tool results in graph
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