A qualitative study of charge nurse competencies

MedSurg Nursing, Oct, 2003 by Lynne M. Connelly, Linda H. Yoder, Denise Miner-Williams

Effective nursing leadership is paramount in the modern health care setting, where complex, high-acuity inpatients are the norm. The best clinical leaders possess competencies in a variety of cognitive and behavioral areas. The charge nurse role evolved from a need to have unit leaders other than the head nurse manage patient care in the absence of the head nurse or during evening and night shifts. The charge nurse role is critical because of current staffing issues, the use of agency and/or foreign nurses, and the need for a proficient nurse to be accountable for issues arising in the unit. In short, charge nurses must take ownership for all unit activities during their shift.

Effective charge nurses mesh administrative, educational, and clinical expertise with an understanding of basic leadership principles (Cartier, 1995). Charge nurses generally come from the most obvious pool of nurses, clinical staff nurses. Unfortunately, these nurses are often academically and administratively unprepared to assume clinical leadership positions (Cartier, 1995).

Unprepared charge nurses create problems of first-line leadership, such as failure to adequately supervise other staff. Quality can be affected, especially in areas where the most acutely ill patients receive care. Orienting nurses to the charge nurse role and planning leadership education courses can be difficult because few clearly delineated competencies appear in the literature. Because there is a lack of research, or even current, general information concerning this clinical role, a study was conducted to determine the competencies necessary to be a successful charge nurse. The findings from the research are presented along with application for current practice.

Background

Although many hospitals use charge nurses, there is a lack of clear guidelines concerning the role, competencies needed for optimum role performance, and criteria for evaluating performance. Many recent articles offer advice to the new charge nurse (Costello-Nickitas, 1997; Shermont & Russell, 1996; Sonnenberg, 1999), to managers about the role (Zimmerman, 2000), or about the legal responsibilities of the team leader and charge nurse based on litigation (Mahlmeister & Koniack-Griffin, 1999).

In one of the few studies about the role, Bostrom and Suter (1992) examined charge nurse decision making concerning patient assignments. They concluded that experienced charge nurses considered more factors in making assignments and relied less on the acuity system than did novice charge nurses. Some authors have described the role of the charge nurse as multifaceted, including duties of patient care, hospital protection, and staff interaction. In an Australian survey study, Chaboyer, Najman, and Dunn (2001) found no difference between Level I (staff nurses) and Level Il/Ill (charge nurses) on perceptions of cohesiveness in their interactions with each other in the working environment at three large, tertiary care hospitals (N=555). All nurses reported a moderate amount of cohesion among themselves.

Overall, the charge nurse has been considered to be responsible for maintaining appropriate standards of care and professional staff/patient interactions (Hinkle & Hinkle, 1977). Now, with increasing patient acuity levels and shorter hospital stays, the role of the charge nurse has become integral to optimum patient care in moderate-to-large sized medical facilities throughout the United States, especially in military facilities. In addition, this position often provides the first opportunity for exercising the leadership skills that nurses will use throughout their careers. Therefore, identifying the competencies is needed by the charge nurse for achieving effectiveness in this role and was the aim of the study reported in this article.

Conceptual Framework

Competencies were conceptualized as the expectations that professionals have for a particular role. Therefore, it was considered appropriate to interview nurses at various levels who interact with charge nurses to determine the competencies for that role. Generally, qualitative researchers do not propose a framework to guide the research prior to a study. The researchers desire to stay open to what the informants are saying and develop a theory based on the research. In this study, researchers took a slightly different approach. In order to provide a starting point for the semi-structured, open-ended interview questions, they used Katz's (1974) three broad categories of management skills--technical, human, and conceptual--to form the initial interview questions. For example, one question was, "What technical skills do you think a charge nurse needs to possess?" However, informants were allowed to explore what they perceived to be important to the subject of charge nurse competencies.

Methodology

An exploratory, qualitative research design was used in this study. The research question was: "What do nurses at various levels perceive to be the competencies needed to effectively carry out the role of charge nurse in a military medical center?" Although military nursing has certain differences when compared to civilian nursing (such as readiness to deploy and functioning in a variety of settings), the research team believed the study would have applicability to both military and civilian nursing. A stratified, purposive sampling technique (Patton, 1990) was used to select a heterogeneous group of informants representing each level of nurses (staff, charge, head nurse, supervisory) from a variety of different clinical areas until there was saturation of data categories. As mentioned above, competencies were conceptualized as the expectations that professionals have for a role; therefore, it was important to include a wide range of people involved with the role. In addition, a qualitative interview approach was thought to be the best means of exploring expectations people had for the role.