In the past decade, there has been a shift in health care toward decreasing hospital visits and length of stay, resulting in increased outpatient care and acuity. From 2013 to 2014, the use of outpatient services increased by 3.7%. Over the past 8 years, the cumulative increase was 44% (Medicare Payment Advisory Commission, 2016). This trend has continued due to changes with insurance coverage and billing, increased outpatient observation services, and hospitals purchasing freestanding physician offices (Medicare Payment Advisory Commission, 2016). This led to the need for clinically competent and experienced nurses in the outpatient setting (Institute of Medicine, 2010). The charge nurse is a necessary leadership role in health care and can ensure seamless patient flow while delivering safe, efficient, and high-quality care. With the shift to increased outpatient care, this role has new importance outside of the traditional inpatient setting.
The responsibilities of a charge nurse are continuously evolving and not always clearly defined. The role requires a clinical expert to work collaboratively with the multidisciplinary team to promote an efficient work environment, ensure unit safety, and maintain patient and staff satisfaction (Flynn, Prufeta, & Minghillo-Lipari, 2010). The charge nurse increases unit productivity through improved communication between the nursing staff and clinical team members. Additionally, charge nurses foster teamwork, therefore increasing retention (Flynn et al., 2010). Despite the value the charge nurse has demonstrated in patient care and nursing retention, the responsibilities are largely left for the nurse to learn on the job, as there is a lack of standardized education and training (Flynn et al., 2010; Homer & Ryan, 2013).
At one large academic medical center, five separate out-patient infusion units within the same building came under the management of a new nurse manager. Each infusion unit treated different patient populations, had a different operational workflow, and had their own process for training new charge nurses. Collaboration and communication was also lacking among charge nurses in different units. The varying styles of the charge nurses and the general disconnect between the units negatively affected staff satisfaction, nurse manager satisfaction, and unit workflow. This article describes the development, implementation, and outcomes of a charge nurse orientation program in the outpatient health care setting to address these issues.
A literature review was conducted to examine the current evidence on the charge nurse role and best practices for education and orientation. The databases used were CINAHL® and PubMed®. Search terms included leadership, charge nurse, orientation, education, training, ambulatory, outpatient, and infusion. Articles included in the review were in the English language, published from 2011 to 2016, and focused on the charge nurse role. Results were minimal; therefore, search criteria was expanded to 2004. A total of 15 articles were found; however, none of them addressed the training of charge nurses specific to the outpatient setting.
Literature demonstrated that nurses in the charge nurse position often function without standardized training and competency (Homer & Ryan, 2013). Little is known of what is required to prepare nurses for the role or the best way to ensure their ongoing development (Eggenberger, 2012). Homer and Ryan (2013) found that a training program on the role of the charge nurse led to increased confidence and knowledge in communication, conflict resolution, and giving constructive feedback. Similarly, others came to a consensus that creating a formalized education program benefits nurses pursuing this role by increasing their competency and leadership skills (Patrician, Oliver, Miltner, Dawson, & Ladner, 2012).
Another common theme that emerged was the identification of the barriers and facilitators of the charge nurse role. Barriers such as complexity of the role, increased workload, time constraints, and lack of leadership support were identified (Rankin, McGuire, Matthews, Russell, & Ray, 2016). Juggling patient care and leadership responsibilities was found to be a consistent obstacle. These barriers, along with a lack of leadership development and education, can create a negative perception of the charge nurse role. As a result, many competent and qualified nurses avoid taking on this position (Thomas, 2012).
Facilitators included increased supervisory time, adequate staffing, support for the role, and effective leadership skills (Rankin et al., 2016). For charge nurses to succeed, they need support from both their managers and colleagues (Rankin et al., 2016). Many sources referenced the need for effective leadership skills. Attributes such as conflict resolution, problem solving, and time management were found to be key factors for success in the role (Flynn et al., 2010). When charge nurses possess these attributes, the role was seen in a more positive light.
An implementation team consisting of six experienced charge nurses, a clinical nurse specialist, and an administrator was formed. These current charge nurses were clinical experts in their areas and familiar with hospital policies and procedures. Given the dearth of existing literature regarding an outpatient charge nurse education program, the implementation team developed a program bridging the unique needs and common themes in the literature. This included leadership development, communication skills, and time and workload management. This team aligned the program with the standards of the institution's professional practice model, relationship-based care.
The relationship-based care model recognizes the importance of relationships with patients, caregivers, colleagues, and self to enhance quality, safety, and satisfaction initiatives. The relationship and commitment between health care team members in establishing quality care for patients has been shown to improve the patient's commitment to their own care (Koloroutis, 2004). Using the relationship-based care model and a shared-governance framework, the institution supports frontline nursing staff involved in the implementation, collaboration, and development of improved patient care.
The implementation team executed the program in two cohorts. The first cohort was comprised of the existing, experienced charge nurses. This served to standardize the role, reeducate on expectations, and revitalize current charge nurses who had expressed burnout. The second cohort consisted of educating nurses new to the charge nurse role. Nurses who possessed clinical expertise, problem-solving skills, leadership qualities, and professional communication skills were chosen collaboratively with the nurse manager to attend.
A presurvey was sent to both cohorts (n = 17) prior to the program to identify their baseline knowledge and comfort in the charge nurse role. A 4-point Likert scale focused on comfort levels in the role, use of the patient scheduling system, and knowledge of unit operations. The presurvey revealed that 70% (n = 12) of respondents reported feeling comfortable before the program (Figure 1). Alarmingly, only 23% (n = 4) of the nurses knew how to navigate through the patient scheduling system, which is an essential tool to understand while managing a busy outpatient infusion unit (Figure 1).
Pre- and postsurvey results of the charge nurse orientation program.
Using the survey results and literature review, the implementation team developed a program consisting of 1 classroom day and 2 days of precepting (Figure 2). The learning objectives of the program included understanding the expectations of the role and identifying the tools needed to succeed, while taking into consideration the similarities and differences between the five units.
Charge nurse orientation program outline.
Note. CNS = clinical nurse specialist.
Classroom content included a didactic lecture, case studies, open discussion, and journal readings and was completed by all participants. The didactic portion included topics such as unit operations specific to the outpatient setting, promoting the institution's professional practice model, handling complex patient and staff situations, and the development of leadership skills such as problem solving and communication. Journal readings focusing on the development of charge nurse programs were assigned 1 week prior. To address the survey results related to knowledge deficits with the scheduling system, the team collaborated with the administration to provide hands-on training. Participants were also required to attend a class on communication or conflict management through the Learning & Organizational Development department of the hospital. Due to the limited availability of this class, not all participants were able to complete the class prior to the postsurvey; however, all did take the class at some point during the year.
After the classroom content was completed, all participants were assigned to shadow an experienced host charge nurse. This provided the opportunity to network with other charge nurses, observe different leadership styles, and gain a better understanding of the infusion units. Participants were given multiple resources, which included various templates for staffing and interdepartmental contact information. A checklist was also provided for the individuals, which served as a guide on the required topics to review during the shadow experience (Table 1).
Charge Nurse Orientation Checklist
For 2 days, new charge nurses from the second cohort were also assigned a preceptor who would educate them on the charge nurse role. The preceptors were the experienced nurses who completed the program in the first cohort. The team felt that because these nurses completed the program successfully, the values and education provided would be reflected in the preceptorship.
Effective programs require preceptors to have support and guidance from nursing leadership; therefore, this was integrated as a formal part of the program (McClure & Black, 2013). At the end of the orientation program, the new charge nurse and preceptor met with the nurse manager and clinical nurse specialist to review the responsibilities of a charge nurse within the area. This meeting also served as a platform for the nurse manager to formally express their support and guidance during this new transition.
The effectiveness of this educational opportunity was evaluated by comparing the participants' pre- and postsurvey responses (Figure 1). The number of participants that completed the postsurvey was 76% (n = 13). There was a 30% improvement in comfort with the charge nurse role, a 328% improvement in comfort using the patient scheduling system, and a 31% improvement in familiarity with the operations of other units. All participants (100%) expressed that they would recommend this course for future charge nurses managing a busy outpatient infusion unit.
Feedback and qualitative themes from write-in comments on the postsurvey included existing charge nurses' appreciation for reeducation into the role and reduced inconsistencies between units. Novice charge nurses expressed feeling more prepared and confident in performing their duties. They also expressed enjoying the opportunity to shadow and network with other nurses on neighboring units. One nurse responded:
Spending time with charge nurses on each floor helped me realize differences between units and I was able to observe a few things performed better, which I would like to take away and start in my own unit.
This program led to a sense of improved communication between charge nurses across infusion units. This was apparent by the positive survey results, as well as nurses expressing satisfaction throughout their units. Having an experienced and enthusiastic team of nurses leading this program helped facilitate this leadership opportunity and allowed for the charge nurse role to be updated regularly as the needs of the organization evolve.
As a commitment to ongoing program success, challenges were reviewed. Historically, the charge nurse role is assigned to senior nurses in the units based on their experience (Eggenberger, 2012). Many nurses were open to the idea of unit operations improvement through evidence-based practice, but some remained resistant because they had been practicing a certain way for a long time. Providing nurses with the opportunity to participate in team-building exercises allowed them to reflect on their current practices and mitigate fear of change.
Charge nurses have a large amount of responsibility requiring continuous support from nursing leadership, which is an essential ingredient for success (Patrician et al., 2012). Having the nurse manager's informal and formal support was essential for encouragement throughout program participation, as well as was meeting with the participants and acting as a support system after the program. This was critical in showing the new charge nurses that leadership believed in their abilities and was there to aid them in any challenges they may face.
The team took into consideration the scheduling of five different infusion units, patients, and daily staffing. All nurses worked 12-hour shifts, which made it difficult to plan a structured program. Strategic collaboration of team members was necessary for ensuring units had coverage while their colleagues attended the program. Staffing issues such as vacation, sick calls, or increased patient volume led to rescheduling of different program components. To mitigate this in the future, more advanced scheduling and increased staffing is recommended.
Several suggestions for future sessions of the program arose from the evaluations. Participants requested extending the training component focused on the patient scheduling system and felt more time was needed with their preceptor for hands-on experience in the charge nurse role before being independent. Many felt that 1 day of didactic lecture was insufficient, so a suggestion for future programs would be to extend this part of the program to 2 days. Another limitation was the availability of the Learning & Organizational Development class—not all participants were able to complete the class prior to the postsurvey, although all did take the class at some point during the year. Finally, the survey of the participants was not divided between experienced and new charge nurses; this could have affected the results, given experienced charge nurses may have different needs compared with new charge nurses. In the future, separating these two groups for data collection is suggested.
Standardized programs preparing nurses for the charge nurse role is critical in the sustainment and safety of health care delivery (Krugman, Heggem, Kinney, & Frueh, 2013). With the outcomes noting significant improvement in comfort and knowledge in the charge nurse role, the outpatient charge nurse orientation has become a standard of practice for these five infusion units.
Several opportunities have risen to expand this program to other outpatient sites within the institution. The structure can easily be modified to fit the needs of various sites and reinforce the institution's mission and professional practice model, while at the same time preserving the integrity of the core principles of the program. The need for nursing leadership development in all health care settings is growing and the use of a standard program would address this demand (Patrician et al., 2012).
Nurses in this role require constant mentoring and support from their managers and the institution (Patrician et al., 2012). It is essential to provide ongoing professional development and education at least yearly to cultivate leaders within the frontline nursing staff. Use of this program format, or a modified version, for annual charge nurse refresher training is also possible. To cultivate leaders within frontline nursing staff, institutions should provide opportunities such as personal and professional development courses to teach the skills needed to succeed (Patrician et al., 2012).
With the increased complexity and acuity of the patients seen in the outpatient setting, more knowledgeable and confident frontline nurses are needed in the unit. Charge nurses must be confident in managing complex patient care and possess skills such as problem solving, critical thinking, and clinical expertise (Flynn et al., 2010). Despite this critical position, there is a lack of literature focused on outpatient charge nurses and standardized educational programs to prepare nurses for this role.
This charge nurse training program is feasible and has demonstrated clinical significance in increasing confidence, knowledge, and skills. It is imperative that nurses receive evidence-based training and support from leadership to grow and practice as effective role models in their units. The program could be replicated in any type of health care setting where charge nurses are present due to the flexible format that was used. When a knowledgeable and confident charge nurse with strong clinical skills and judgment is present, the nursing staff feels supported and patients are treated effectively in a high-acuity, fast-paced work environment. Increasing the number of experienced and competent charge nurses in the unit not only fosters teamwork, but also promotes the institution's overall mission and professional practice model.
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Charge Nurse Orientation Checklist
|Meet your host charge nurse.|
|Tour the unit and meet staff (e.g., nurses, patient care technician, sessions assistant).|
|Observe the role of the patient care technician on the unit.|
|Morning touch base and/or noon check in:
Patient list for the day.
Staffing for RNs.
Floating and float logs.
Moving patients off the floor.
Communication with other units about patient transfers, including late report.
|Observe how the charge nurse handles unit operations:
Patient care technician and RN sick calls.
Telephone calls for follow ups and extravasations.
Checking charge nurse e-mail.
Narcotic dispensing cabinet discrepancies and inventory.
Added and cancelled treatments.
Airway cart and equipment check.
Triaging telephone calls and messages from the clinic and medical doctor.
Urgent care center transfers and emergencies.
Lunch and meeting coverage.
How patients are assigned to treatment nursing (i.e., primary nursing).
|Observe how the unit practices primary nursing.|
|Observe responsibilities of the chemotherapy session assistant:
Rooming in patients.
Helping the charge nurse with cadence.
|Observe the charge nurse role in an emergency.|
|Complete late report.
Demonstrate where to find the late medical doctor.
|Observes how and when the charge nurse calls other units to ask for and offer assistance.|