The Journal of Continuing Education in Nursing

Original Article 

Enhancing Trifocal Leadership Practices Using Simulation in a Pediatric Charge Nurse Orientation Program

Teresa J. Clark, DNP, RN, HCA, MS, CPON; Patricia S. Yoder-Wise, RN, EdD, NEA-BC, ANEF, FAAN

Abstract

Click here to read a Letter to the Editor about this article.

 

A well-established charge nurse orientation program was enhanced with the addition of a simulation, addressing three primary populations (the trifocus) with whom charge nurses interact: patients, patients’ parents, and other staff members. In this pilot quality improvement project, 20 staff nurses enrolled in the orientation program and were assigned a mentor. Only one participant used the mentorship opportunity; therefore, it is not discussed here. Twelve nurses completed all charge nurse classes and a simulation scenario of caring for a deteriorating infant. The nurses were given an opportunity to reflect on leadership practices after the simulation. Thematic analysis from qualitative, reflective data supported the enhanced understanding of managing complex patients, a code situation, and teams; guiding a team’s novice nurse; leading as a charge nurse; and using clinical and critical thinking skills. All nurses reported that the simulation as experiential learning helped them to meet their leadership goals.

J Contin Educ Nurs. 2015;46(7):311–317.

Dr. Clark was Chief Nursing Officer, and Vice President of Nursing, Cook Children’s Medical Center, Fort Worth; and Dr. Yoder-Wise is Professor and Dean Emerita, Texas Tech University Health Sciences Center School of Nursing, Lubbock, Texas.

During the publication process, Dr. Clark became too ill to provide correspondence. Special recognition is extended to her husband, Bob Clark, who assisted with completing this process prior to her death, and to her colleague, Dr. Orlando Chapa, Assistant Vice President of Nursing, Cook Children’s Medical Center.

Dr. Yoder-Wise was not involved in the editorial process for this manuscript. Special thanks is extended to whoever served as the editor pro tem for this manuscript.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

† Deceased.

 

Address correspondence to Patricia S. Yoder-Wise, RN, EdD, NEA-BC, ANEF, FAAN, Professor and Dean Emerita, Texas Tech University Health Sciences Center School of Nursing, 7309 93rd Street, Lubbock, TX 79424; e-mail: psywrn@aol.com.

Received: April 15, 2015
Accepted: May 14, 2015

Abstract

Click here to read a Letter to the Editor about this article.

 

A well-established charge nurse orientation program was enhanced with the addition of a simulation, addressing three primary populations (the trifocus) with whom charge nurses interact: patients, patients’ parents, and other staff members. In this pilot quality improvement project, 20 staff nurses enrolled in the orientation program and were assigned a mentor. Only one participant used the mentorship opportunity; therefore, it is not discussed here. Twelve nurses completed all charge nurse classes and a simulation scenario of caring for a deteriorating infant. The nurses were given an opportunity to reflect on leadership practices after the simulation. Thematic analysis from qualitative, reflective data supported the enhanced understanding of managing complex patients, a code situation, and teams; guiding a team’s novice nurse; leading as a charge nurse; and using clinical and critical thinking skills. All nurses reported that the simulation as experiential learning helped them to meet their leadership goals.

J Contin Educ Nurs. 2015;46(7):311–317.

Dr. Clark was Chief Nursing Officer, and Vice President of Nursing, Cook Children’s Medical Center, Fort Worth; and Dr. Yoder-Wise is Professor and Dean Emerita, Texas Tech University Health Sciences Center School of Nursing, Lubbock, Texas.

During the publication process, Dr. Clark became too ill to provide correspondence. Special recognition is extended to her husband, Bob Clark, who assisted with completing this process prior to her death, and to her colleague, Dr. Orlando Chapa, Assistant Vice President of Nursing, Cook Children’s Medical Center.

Dr. Yoder-Wise was not involved in the editorial process for this manuscript. Special thanks is extended to whoever served as the editor pro tem for this manuscript.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

† Deceased.

 

Address correspondence to Patricia S. Yoder-Wise, RN, EdD, NEA-BC, ANEF, FAAN, Professor and Dean Emerita, Texas Tech University Health Sciences Center School of Nursing, 7309 93rd Street, Lubbock, TX 79424; e-mail: psywrn@aol.com.

Received: April 15, 2015
Accepted: May 14, 2015

Frontline leaders are often referred to as managers. Yet, in nursing, a vital role exists that represents the first level of formal leadership. That role is commonly referred to as charge nurse (CN). CNs represent the role of an individual who makes certain that a team on a given shift accomplishes its work and that issues related to work flow and competence are addressed in a timely manner. Preparing CNs to assume this entry-level nursing management role has often been neglected (Patrician, Oliver, Miltner, Dawson, & Ladner, 2012). Even organizations that have developed transition programs for this role do not always use simulation to enhance the learning that new leaders may need to assume the CN role. This article describes the introduction of a leadership simulation in a specialized clinical setting to enhance preparedness of CNs to assume their roles.

Background

This project was undertaken at one children’s health care system located in the southwestern United States. This 430-bed facility is a nationally ranked pediatric facility and holds Magnet® designation. Further, it was designated as a “Best Place to Work” (Modern Healthcare, 2012) and has received The Leapfrog Group’s designation as a top children’s hospital. More than 1,200 RNs are employed in this facility, and each unit (N = 16) and each 12-hour shift has a designated CN.

To help competent, direct-care nurses assume the role of a CN, nurse educators and senior nursing leadership created CN courses. Several CN courses offered through the continuing education program were designed to focus on (a) common issues that arise during a typical shift, (b) how to resolve those issues, and (c) how to provide appropriate follow up. These courses comprise eight class sessions, for a total of 20 hours, and four online courses, for a total of 2 hours. They include such elements as communication, conflict, preventing harassment, clinical delegation, and accountability.

Because a parent accompanies most children for medical care, a CN is often working with at least three individuals: the child (patient), the staff person, and the parent(s) (the trifocus). Although course content was focused on addressing this complexity, no experiences were previously incorporated that allowed prospective CNs the opportunity to test their resolution skills. After considering a new approach to orienting CNs, the chief nursing officer (T.J.C.) decided to include, in addition to another strategy of providing a mentor, a simulated experience, where competency-based CN leadership skills could be enacted. Although the mentorship experience was deemed to be supportive of role transition, only one nurse completed that portion of the enhanced experience. Therefore, this article describes only the simulation and the related evaluations by the learners.

Literature Synthesis

Although simulations, including leadership-related scenarios, have been used in the preparation of prelicensure nursing students, such an effort has not been as dramatic in clinical settings. The ultimate goal for clinical setting simulation centers is to design a full health care system, such as that described by Ross and Crusoe (2014), so learners are constantly exposed to new situations. Students (RNs completing their baccalaureate degrees) were engaged with a virtual system, where real issues, such as quality and safety, were inherent in the scenarios. Although Ross’ and Crusoe’s motivation was to provide this experience due to limited clinical experiences, such a learning tool has great value for clinical nurses.

Simulation may be the only practical and effective way to make health care professionals aware of and understanding of the importance of teamwork and the individual aspects of team performance at a distance from real patients. As noted by Paris, Salas, and Cannon-Bowers (2000), well-constructed simulation scenarios allow participants to explore the different roles within a team, including the important skills required for leadership. Waxman and Delucas (2014) indicated that “Simulating situations in a realistic-looking environment can be effective in building leadership skills” (p. 25). Further, Patrician et al. (2012) identified that educating CNs, a role that is entry level in leadership positions, was critical. They found that little education was focused on CNs and that simulation was vital to making the education relevant. Although the author’s (T.J.C.) hospital had provided education for CNs, it had not incorporated a simulated experience as a way for emerging CNs to demonstrate the expected competencies.

Charge Nurse Role

Hospitals need effective frontline leaders who can manage patient care and operation of the unit. Unit leaders, such as CNs, can have a direct effect on nurse satisfaction, patient satisfaction, patient safety and outcomes, and the fiscal status of the health care organization. In many organizations, the role of the CN is to manage the operation of the patient care area for a specific shift. These responsibilities include staffing; managing patient admissions, discharges, and transfers; and coordinating patient-care activities. Effective conflict resolution between and among members of the health care team and facilitating service recovery around patient complaints are also requirements of the CN role.

Ethical Considerations

The institutional review board determined that the project did not meet the definition of research; therefore, it was presented to the Nursing Quality in Practice Council and was accepted as a quality improvement project.

Purpose

The purpose of this quality improvement project was to offer CNs an opportunity to complete the already-defined leadership courses through the organization’s learning laboratory in a structured approach by utilizing a cohort. Along with the course curriculum, the CN learners were assigned a mentor to assist them with the transition to the CN role. Further, they completed a complex simulation scenario. The desired outcome for the CNs in this cohort was to demonstrate improved competencies in communication skills, conflict resolution, and collaboration.

Method

Sample

Nurse managers selected appropriate nurses who could complete the Charge Nurse Leadership Cohort Program in its entirety. In addition, those who had been in the CN role for less than 6 months were eligible to participate. A total of 20 eligible CNs agreed to join the program; 12 CNs completed both the simulation scenario and the reflections. Table 1 summarizes the demographics of the original group.

Charge Nurse Cohort Demographics (N = 20)

Table 1:

Charge Nurse Cohort Demographics (N = 20)

Simulation Scenario

The simulation addressed the three attributes of competence acquisition—environment, demonstration, and evaluation—as described by Hansen and Bratt (2015). Roles were assigned to the CN learners upon entering the simulation laboratory. One participant from the CN cohort was asked to role-play the bedside nurse. This nurse acted as a novice nurse who is uncertain why his or her patient’s status is changing. Another participant was assigned to role-play the CN, a third participant played the role of the anxious parent, and a high-fidelity simulation manikin was used as the child. Every nurse in the cohort had the opportunity to role-play the CN.

The novice nurse was instructed to act uncertain about the assessment findings, how to proceed, and how to interact with the anxious parent. This nurse was to always defer to the CN. Several vital signs that suggested a deterioration in the child’s condition were presented. The CN was instructed to work with the novice nurse, with the CN being able to observe the nurse’s hesitancy to provide care. As the child’s condition continued to deteriorate, the child’s mother became increasingly anxious; thus, the CN had to provide comfort and reassurance and identify a plan for the anxious mother.

Evaluation of the Simulation

At the close of the simulation, each participant completed two tools. One tool was a seven-question evaluation rubric, with four questions addressing cognitive performance and three addressing behavioral performance (Table 2). The observers (raters) of this competency performance were educators within the organization who were responsible for competency assessments. A second tool posed the following three questions based on the learners’ reflections (Tables 35):

  1. How would you describe your role as a charge nurse in this experience?

  2. What did you learn about yourself and your abilities to encourage teamwork and enable others to act?

  3. Now, what does this experience mean to you as you lead the health care team?

Evaluation Rubric for Simulation Analysis

Table 2:

Evaluation Rubric for Simulation Analysis

Themes Derived from Simulation Reflections on Role of Charge Nurse

Table 3:

Themes Derived from Simulation Reflections on Role of Charge Nurse

Themes Derived from Simulation Reflections on Self-Learning and Teamwork

Table 4:

Themes Derived from Simulation Reflections on Self-Learning and Teamwork

Themes Derived from Simulation Reflections on Personal Meaning of Leadership Experience to Lead a Health Care Team

Table 5:

Themes Derived from Simulation Reflections on Personal Meaning of Leadership Experience to Lead a Health Care Team

Results

Evaluation Rubric for the Charge Nurse Simulation

Descriptive statistics were obtained for each of the study measures. An observer, using a Likert-type scale of seven questions, scored each of the participants. The tool, developed by Stacey Bancroft, MSN, RN, CPN, was based on specific literature (Gantt, 2010; Parker & Myrick, 2010; Penprase et al., 2012). Table 2 presents those performance expectations. The scale ranged from 1 = objective not met, 2 = objective partially met, and 3 = objective met. No participant was scored with a 1. All responses were scored with a 3, except for one participant, who was scored with a 2 on three items.

Although these quantitative data suggest that participants achieved all objectives, the qualitative data from the reflections form suggest more practice is required, especially when implementing care while supporting a novice nurse and an upset or anxious parent. Oermann, Kardong-Edgren, and Odom-Maryon (2012) suggested that frequent practice produced better results when working with undergraduate nursing students around the skill of cardiopulmonary resuscitation. Perhaps the same is true when working with new CNs in developing their trifocal skills.

Reflections on the Charge Nurse Simulation

Participants were allowed to take as much time as needed to complete the three-question form. All forms were reviewed across questions, and repeated words, phrases, and concepts were highlighted. Subsequently, groupings were made relating to the expected competency areas and the expected learning outcomes to form themes. The themes related to the role of the charge nurse were Complexity of Managing a Patient Situation, Complexity of Managing Parents, and Complexity of Managing the New Nurse. The themes related to self-learning and teamwork were Complexity of the CN Role, Complexity of Managing Teamwork, Focus on Clinical Skills, and Complexity of the Code Situation. Finally, themes related to the personal meaning of leadership were Meeting Leadership Goals Through Simulation and Simulation as Experiential Learning.

Samples of respondents’ statements regarding the role of a CN are presented in Table 3. The general themes related to the complexity of managing three elements—the patient situation, the patient’s parent(s), and the new nurse. Some learners identified the simulation scenario as being particularly challenging because they were used to working with their established teams, which were highly competent. They also acknowledged that working with one’s own team was easier due to being able to anticipate the needs of their coworkers.

Samples of respondents’ statements regarding the self-learning that occurred and how to encourage teamwork are presented in Table 4. Reflections on self-learning and teamwork seemed to address the complexity of having a trifocus when caring for a pediatric patient. Some respondents seemed to focus on their clinical skills of handling a code or medical alert situation. However, most respondents saw the complexity of the code as having an overlay of the CN role.

The final focus was on what this experience meant to the participants in terms of leading a health care team. Samples of respondents’ statements are presented in Table 5. The belief that this situation was similar to PALS (Pediatric Advanced Life Support), but with the overlay of a novice nurse and anxious parent(s), suggested that the simulation experience met its goal of identifying what it means to be a CN in a pediatric acute care organization. The theme of this experience serving as practice, with that practice enhancing one’s ability to execute complex behaviors well, has implications for other areas of practice, where nurses may have been more focused on psychomotor skills, rather than the complexity of the real world.

Discussion and Lessons Learned

The desired outcomes for implementing the CN cohort with mentoring and simulation were to improve the quality of leadership development for CNs and enhance competencies in communication skills, conflict resolution, collaboration, and change. Providing a simulation where CNs experience the trifocus of serving in the CN role in a pediatric setting allowed the CNs to gain insight into the complexity of the role. The dilemmas of balancing (e.g., delegation versus “not being nice” and the sense of control versus trying not to take over) created the potential for further discussions regarding the CN role. Although most CNs achieved a score of 3 (objective met consistently and without hesitation), the feedback on both cognition and performance was useful to participants as validation of their work in simulation. The simulation scenario took time to develop and implement, and it also provided the opportunity to integrate and synthesize classroom content into a clinical management situation that CNs were likely to encounter.

Conclusion

The simulation literature identifies numerous outcomes related to various performance expectations. Simulation enables the effective development of transferable, transformational leadership skills; has improved students’ critical thinking and clinical reasoning in complex care situations; and aids in the development of students’ self-efficacy and confidence in their own clinical abilities (Lewis, Strachan, & Smith, 2012). This quality improvement project reflects those same outcomes.

Further, the CN reflections indicated that those involved in the trifocal simulations believed that incorporating ongoing simulations would benefit their ability to work through emergency situations; would more effectively help them to cope with stressful situations with parents, children, and team members; and would assist them with working through crisis situations.

References

  • Gantt, L.T. (2010). Using the Clark Simulation Evaluation Rubric with associate degree and baccalaureate nursing students. Nursing Education Perspectives, 31, 101–105.
  • Hansen, J. & Bratt, M. (2015). Competence acquisition using simulated learning experiences: A concept analysis. Nursing Education Perspectives, 36, 102–107. doi:10.5480/13-1198 [CrossRef]
  • Lewis, R., Strachan, A. & Smith, M.M. (2012). Is high fidelity simulation the most effective method for the development of nontechnical skills in nursing? A review of the current evidence. The Open Nursing Journal, 6, 82–89. doi:10.2174/1874434601206010082 [CrossRef]
  • Modern Healthcare. (2012, October12). Best places to work in healthcare. Retrieved from http://www.modernhealthcare.com/article/20121010/INFO/310059996
  • Oermann, M.H., Kardong-Edgren, S.E. & Odom-Maryon, T. (2012). Competence in CPR. The American Journal of Nursing, 112(5), 43–46. doi:10.1097/01.NAJ.0000414320.71954.34 [CrossRef]
  • Paris, C.R., Salas, E. & Cannon-Bowers, J.A. (2000). Teamwork in multi-person systems: A review and analysis. Ergonomics, 43, 1052–1075. doi:10.1080/00140130050084879 [CrossRef]
  • Parker, B. & Myrick, F. (2010). Transformative learning as a context for human patient simulation. Journal of Nursing Education, 49, 326–332. doi:10.3928/01484834-20100224-02 [CrossRef]
  • Patrician, P.A., Oliver, D., Miltner, R.S., Dawson, M. & Ladner, K.A. (2012). Nurturing charge nurses for future leadership roles. The Journal of Nursing Administration, 42, 461–466. doi:10.1097/NNA.0b013e31826a1fdb [CrossRef]
  • Penprase, B., Mileto, L., Bittinger, A., Hranchook, A.M., Atchley, J.A., Bergakker, S.A. & Franson, H.E. (2012). The use of high-fidelity simulation in the admissions process: One nurse anesthesia program’s experience. AANA Journal, 80, 43–48.
  • Ross, A.M. & Crusoe, K.L. (2014). Creation of a virtual health system for leadership clinical experiences. Journal of Nursing Education, 53, 714–718. doi:10.3928/01484834-20141120-03 [CrossRef]
  • Waxman, K.T. & Delucas, C. (2014). Succession planning: Using simulation to develop nurse leaders for the future. Nurse Leader, 12(5), 24–28. doi:10.1016/j.mnl.2014.07.009 [CrossRef]

Charge Nurse Cohort Demographics (N = 20)

Demographicn (%)
Gender
  Female19 (95)
  Male1 (5)
Age
  <40 years old18 (90)
  ⩾40 years old2 (10)
Educational level
  Baccalaureate degree13 (65)
  Associate degree7 (35)
Years in practice
  <5 years12 (60)
  ⩾5 years8 (40)
Shift worked
  Days10 (50)
  Nights10 (50)

Evaluation Rubric for Simulation Analysis

Competency Area/ObjectiveScorea
Cognitive performance
  Identifies clinical problems using critical thinking and assessment strategies
  Verbalizes the possible physiologic causes of the patient’s clinical problems
  Anticipates interventions needed to support the staff, the patient’s family, and the patient
  Identifies how interventions would be carried out, and/or who would need to be notified to complete interventions and address the clinical issue.
Cognitive performance total score
Behavioral performance
  Identifies when to call for assistance and what resources are available to assist in solving the problem associated with the patient scenario
  Coordinates the team, or identifies how the team would need to be coordinated, for completion of the activity and keeps the team on task
  Uses therapeutic communication with all team members, the patient, and family members while promoting family-centered care at all times
Behavioral performance total score
Combined score (maximum = 21)

Themes Derived from Simulation Reflections on Role of Charge Nurse

General ThemeReflection
Complexity of Managing Patient SituationMultitasker

Reassure mom and answer questions while providing critical interventions to the patient

Bring clinical skills, delegate appropriately, call for needed help

Calm voice of reason

Need to be the calm voice of reason, both clinically and situationally

Lead and facilitate actions from nurses

Recognize own discomfort in unfamiliar situations

Rapid responder

Give attention to each challenge

Know how to quickly assess patient and situation

Delegator

Call in appropriate resources when situation escalates

Delegate tasks to others

Call for more support

Complexity of Managing ParentsServe

Serve to educate and help calm parents and make them feel part of their child’s care

Serve as fire extinguisher

Need to facilitate communication between the parent(s) and unfolding circumstances

Navigate

Try to navigate both the clinical and parent experience

Be a calming presence

Deal with calming down an upset, hypervigilant, or anxious parent, while dealing with the critical patient

Need sense of calmness to explain what is happening

Comfort

Need to comfort parent(s)

Complexity of Managing the New NurseTeacher

Provide knowledge and skills to new nurse

Coach

Encourage nurse to walk through all of the steps; need to coach new nurse in critical role

Director

Direct new nurse to correct interventions

Need to direct staff to roles during a medical alert or code

Themes Derived from Simulation Reflections on Self-Learning and Teamwork

General ThemeReflection
Complexity of Charge Nurse RoleBalance

Balance teaching and doing at same time

Learn how to work with different personalities

Talk to parent(s) and help new nurse

Strong calm voice

Stay objective and give feedback to the team.

Assist, encourage, and praise novice nurses.

Debrief with staff after situation occurs

Help diffuse situation with angry parent(s) and provide education and reassurance

Remain calm when others are anxious—redirect their anxieties.

Confidence

Need for confidence in knowledge and capabilities

Complexity of Managing TeamworkDelegate

Need to delegate and instruct others on what needs to be done

Have all available resources ready for team

Leader has a lot of influence on how well the team works together

Give team members tasks so that the charge nurse has time to think.

Not being nice

Sometimes I have a hard time telling people what to do (“not being nice”), but as a charge nurse I don’t have that option.

Better to instruct the new nurse to do, rather than to take over and do everything

Focus on Clinical SkillsCritical thinking

Use of my critical thinking skills to take care of the patient

Patient safety

Need to allow for the best safety of the patient

Complexity of the Code SituationSense of control

Need to act with authority and confidence

Resources are important, but sometimes you have to take control of the situation.

Need to communicate active details during a code

Try not to take over

I cannot run a code alone—it is important to work with a team that is well prepared.

Themes Derived from Simulation Reflections on Personal Meaning of Leadership Experience to Lead a Health Care Team

General ThemeReflection
Meeting Leadership Goals Through SimulationExplain

Remember to explain what you are doing so that the parent(s) understands why things are happening

Direct

Direct new nurses in nonthreatening ways so they are able to help to provide needed interventions

Teach

Teach novice nurses

Know

Know who and what are your resources

Care

Be a resource, and be open to anyone without bias to provide support

Importance of caring and involving the parent(s) in different situations

Delegate

Information and delegation is the key

Simulation as Experiential Learning

Reinforce leadership skills and give the opportunity to improve skills

Realize the responsibilities I have to step up and lead others by example

Walk through necessary steps

Similar to PALS (Pediatric Advanced Life Support) but added novice nurse and angry parent(s)

Helpful to practice delegation and leadership during stressful times

Each time we practice, it builds my confidence and makes the “real event” smoother

Opened my eyes to some things I can improve on to help me be a better charge nurse

Key Points

Leadership

Clark, T.J. & Yoder-Wise, P.S. (2015). Enhancing Trifocal Leadership Practices Using Simulation in a Pediatric Charge Nurse Orientation Program. The Journal of Continuing Education in Nursing, 46(7), 311–317.

  1. Having a trifocal view (patient, parent, team member) helps new leaders gain relevant leadership experiences in simulation.

  2. Simulation experiences enrich didactic learning by allowing for integration and synthesis of knowledge and skills into clinical management performances.

  3. Pediatric simulations that are designed to include the role of the parent create realistic situations.

10.3928/00220124-20150619-02

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