By Stacey Kusterbeck
In the ED, the charge nurse role is “critical to facilitate effective and safe care — and, arguably, the most important role on a shift,” says Lisa A. Wolf, PhD, RN, CEN, FAEN, FAAN, director of emergency nursing research for the Emergency Nurses Association.
However, most charge nurses undergo little or no training for the role.1 Wolf and colleagues conducted previous studies focused on bullying in the ED.2,3 “In those two studies, we identified that the charge nurse plays a pivotal role in facilitating or challenging bullying narratives,” Wolf says.
One reason is charge nurses are responsible for assigning patients to nurses. “In some cases, charge nurses can do that job in a way that overwhelms nurses. That sets nurses up for failure, and it’s not good for patients,” Wolf explains.
After Wolf and colleagues identified the charge nurse as an influential player, the next step was to learn more about the role itself. “We needed to find out how charge nurses are prepared for their role so that we could consider interventions targeted at that particular role,” Wolf shares.
In the most recent study, Wolf and colleagues focused on charge nurse training. “Charge nurses are not really management and not really staff. It’s a really hard job to do if you don’t have the full support of the people above you and the people below you,” Wolf explains.
Years ago, Wolf completed six weeks of training before assuming a charge nurse role, with about a decade of previous nursing experience. In contrast, most of the 2,579 charge nurses surveyed received little or no training. Most (67%) said their only training consisted of shadowing another charge nurse for a shift or two. About one-third reported no training. “This is a huge problem,” Wolf laments.
Charge nurses are responsible for patient flow, moving them from the waiting room to appropriate disposition. To be effective, these nurses must understand the clinical conditions of the patients in the waiting room. This informs good decision-making on which patients to bring in, in collaboration with the triage nurse, and which nurses to assign those patients. “The charge nurse really has a lot of unrecognized importance,” Wolf says.
Wolf and colleagues also hosted focus groups with charge and staff nurses to gauge how they understood the charge nurse role. The two groups expressed different perspectives. Charge nurses saw their job narrowly — move patients out of the waiting room, put them in front of an EP, and admit or discharge the patient as efficiently as possible.
In contrast, staff nurses viewed the charge nurse role broadly. Staff nurses believed charge nurses should function as a supportive clinical expert and a social expert to defuse tensions among nurses, patients, and families; between nurses and physicians; or between the ED staff and the inpatient floors. “Staff nurses said that the charge nurse sets the tone. Even if a shift is a dumpster fire, if you have a calm and competent charge nurse who’s perceived as supportive of nurses, it will be better than if somebody is micromanaging or ill-prepared for the role. It comes downhill on the whole shift,” Wolf says.
Staff nurses also thought charge nurses needed to maintain an awareness of the entire ED to know which nurses can handle additional patients. “It’s a much more complex understanding of the role that comes to us from the staff nurses,” Wolf says.
Clearly, many charge nurses are thrown into a complex role without appropriate training. Compounding the issue, ED nursing staff often are more inexperienced than in prior years. “There’s a vast deficit of experience in EDs,” Wolf notes. If a nurse has a year of experience as a nurse in the ED, or several years’ experience as a nurse outside the ED, that nurse may be the most qualified nurse in the department, landing him or her in the charge nurse role. “When you think of the importance of this role, and the appalling lack of training people get for it — it’s really dangerous, and can lead to disaster,” Wolf cautions.
Good communication can mitigate many problems. If the charge nurse knows an ED nurse has the only empty bed but just took on the care of two other patients, the charge nurse can circumvent problems by explaining a float nurse will arrive immediately to assist the overwhelmed nurse. “It’s understanding what needs to happen with the patient, that the nurse may not have the time right now to do what is necessary, and how to communicate it so the nurse doesn’t have a meltdown,” Wolf says.
The charge nurse also must understand the realities of the ED in terms of staffing. “Are you dealing with a bunch of brand-new grads? If so, you can’t give really them a bunch of really sick patients, because bad things will happen if they don’t have experience,” Wolf warns.
Formal training in communication, nurse-patient assignment, and situational awareness is critical. Wolf and colleagues are working to identify competencies, with the goal of teaching new charge nurses to translate clinical expertise into clinical leadership. “If you don’t train people well, they fail or get frustrated, rightfully so,” Wolf says.
REFERENCES
1. Wolf L, Perhats C, Delao A, et al. Role and training of emergency department charge nurses: A mixed methods analysis of processes, needs, and expectations. J Emerg Nurs 2022 May 31;S0099-1767(22)00065-4. doi: 10.1016/j.jen.2022.03.009. [Online ahead of print].
2. Wolf LA, Perhats C, Clark PR, et al. Workplace bullying in emergency nursing: Development of a grounded theory using situational analysis. Int Emerg Nurs 2018;39:33-39.
3. Wolf LA, Perhats C, Delao AM, Martinovich Z. Validation of a grounded theory of nurse bullying in emergency department settings. Int Emerg Nurs 2021;56:100992.
Charge nurses are responsible for patient flow, moving them from the waiting room to appropriate disposition. To be effective, these nurses must understand the clinical conditions of the patients in the waiting room. This informs good decision-making on which patients to bring in, in collaboration with the triage nurse, and which nurses to assign those patients.
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