Evaluation of a charge nurse leadership development program

The hospital-based charge nurse (CN) can make or break the team dynamic on the shift. They have extensive responsibilities, but it's more than what they do that's critical, it's how they do it. CNs must use effective communication, influence, delegation, interpersonal relationship-building, and vision-setting skills while executing essential tasks. This is crucial because leadership skills have become more important than ever to reduce nursing turnover postpandemic.1 Unfortunately, CNs often feel unprepared to effectively assume these essential leadership roles.2-4 The nursing leadership at a large, urban teaching hospital in Colorado recognized the value of the CN role. The hospital offered a CN orientation class. Beyond CN orientation, there were organizational development classes, but the content wasn't specifically taught to the role of the CN and participation was lacking. Because of the lack of continuous education focused on developing CN leadership skills within the organization, nurse leaders believed that creating ongoing CN-specific education could be beneficial. Nurse leaders proposed a CNO-approved evidence-based pilot program to support the strategic priority of investing in staff workforce development opportunities. The primary purpose of this pilot study was to evaluate CN participants' self-perception of improved confidence in leadership skills after engaging in a 4-month structured leadership program. What does the literature say? The literature suggests that leadership development programs are beneficial. Kramer and Davies conducted a review of nine studies and concluded that formal orientation and ongoing leadership support is required for CNs to be successful.5 Krugman and colleagues found a significantly higher rating of CNs inspiring a shared vision for direct care nurses after attending an educational program.6 Nurse leader education was found to improve patient safety culture and outcomes.7,8 Dowling Dols and colleagues linked increased patient satisfaction scores regarding nurse communication to a CN training program.3 Finally, multiple studies showed that CNs have a more positive perception of their job performance after training in leadership skills.2-4 Although the benefit of ongoing leadership development has been defined, there are no standardized competencies for CNs.4,5,8,9 Training topic themes found in the literature focus on communication, developing relationships, promoting teamwork, and understanding one's leadership style and self-awareness.2-5,7,8,10,11 Some courses included training on emotional intelligence.4 One theme that was absent in the reviewed literature was training in diversity, equity, inclusion, racism, and bias. Theoretical framework It was important to design this program with theories that CNs could apply to day-to-day work and, in turn, use when leading improvement work on their clinical units. The project leader selected Patricia Benner's From Novice to Expert theoretical framework; although often applied to clinical skills, this theory also has relevance to nursing leadership.12,13 Both a novice and experienced CN may be capable of managing a leadership situation, but the outcome of how well it's managed is attributed to the individual's expertise, aligning with this framework. The program also used Appreciative Inquiry (AI) as the model for change management.14 The core of AI follows the key theme that improvement work in an organization is a mystery to be embraced as opposed to a problem to be solved.14 This idea was helpful to make change management approachable within the context of the CN role. Workshop series The Charge Nurse Leadership Development Workshop Series (CNLDWS) was created to evaluate if implementation of a 4-month structured leadership development program increased CNs' self-perception of confidence in their leadership skills. The project leader also explored commonalities in factors that motivated participant involvement in leadership development. Participants were included if they worked in a hospital-based CN position regardless of years in the role, were in good employment standing, and were willing to attend the classes. There were 111 eligible CNs at the time of course offering; however, because this was a pilot program, the recruitment was limited to 12 CNs from diverse units. To recruit participants, the project leader sent targeted emails to eligible staff and advertised at daily CN patient staffing meetings. Participation was voluntary, without penalty for course discontinuation, and continuing-education credits were provided. The CNLDWS was a 4-month course that consisted of four 90-minute, in-person classes (one per month) followed by an email with related optional multimodal education, such as podcasts, articles, and blogs. CNs were compensated for attendance. All classes were taught by an experienced nurse leader within the organization who filled the role of course lead. The classes were held in four consecutive months (May through August). The CNLDWS curriculum was thoughtfully designed to be specific to the CN role, based on the evidence and the organization's leadership performance expectations. The courses were structured to build on the knowledge learned from class to class and enriched through group discussion. Course topics with subtopics are outlined in Table 1. The first hour of each class provided didactic education. Classes two through four included discussions about applying learned knowledge. The final segment of each class was dedicated to a breakout group AI exercise. Table 1: - Course content overview Class 1 Class 2 Class 3 Class 4 Topic Understanding others Leadership Communication in charge Influencing others: Techniques to motivate Subtopics Diversity (generational, racial) Equity Inclusion Conscious and unconscious bias Hidden rules LPI interpretation LPI: Practices of exemplary leadership Authentic leadership Critical conversations How to prepare for and execute Giving and receiving feedback Documenting conversations Critical conversations: Patients/families Influence: Why it matters Ways to influence Picking the right tactics Recognizing when others are influencing you AI exercise Discovery Within your role as a charge nurse, what actions do you take that support an inclusive work and care environment? On your unit, what practices, processes, or cultural norms do you have that support an inclusive work and care environment? Describe one of your best shifts as a charge nurse. Was there a challenge or a problem? Discuss the situation and what you/others did to make the situation successful. On your poster, write skills, behaviors, or actions that made you successful that day. What makes you a great communicator? On your poster, write skills, behaviors, or actions that made you successful. What factors or tactics do you rely on most when influencing? When have you been successful influencing? Dream: In a perfect world... Within your role as a charge nurse, what actions would you take to support an inclusive work and care environment? What practices, processes, or cultural norms would your unit have that would support an inclusive work and care environment? What skills, behaviors, or actions would describe the best charge nurse you could be? What would “better” look like to build on what you already do well? Think of the best and worst peers, leaders, and people outside of work who have influenced you. What did they do that you want to replicate or avoid? I would be more confident in my crucial conversation skills if I could ______ better. Listen? Respond in the moment? Pick the right words? De-escalate? Maintain positive body language? Better plan for the discussion? Provide better follow-up after? Give more positive feedback? Address issues in the moment? Actually have the conversation? How would you describe a top-notch influencer? Think of a colleague, peer, or boss who's a great influencer. What do they do that seems to work? Design Within your role as a charge nurse, what actions will you start to support an inclusive work and care environment? What practices, processes, or cultural norms from the dream should your unit start that would support an inclusive work and care environment? From the list of the dream state, what are your top one to three leadership skills, actions, and behaviors that you'll start today? Are there any barriers on your unit or team that may hold you back from performing these actions or behaviors? What could you do to break down these barriers? What could you do to get to your dream state? What are one to two actions you could start today to be a better influencer? Destiny How will you know if you've made the personal change you've committed to? What steps will you take to bring your unit's ideas back to your leadership team? How will you know if you've made the personal change you've committed to? How will you know if you've made the personal change you've committed to? How will you know if you've made the personal change you've committed to? After each class session, the course leader distributed an email to participants with a brief course evaluation and optional self-driven learning. There were also six weekly emails sent after the fourth class to foster ongoing engagement in self-paced learning. Multimodal self-study options from nursing and nonnursing sources included journaling; free online podcasts and videos; self-assessment tools; and publications such as books, journal articles, website blogs, and professional documents. Participants had the option be compensated up to 2 hours per week for completing this work remotely with manager approval, as supported by organizational policy. Confidence in leadership skills was measured through a pre-post assessment using the Leadership Practices Inventory (LPI): Self.15 Permission to use the tool was obtained from John Wiley & Sons, Inc. The self-assessment tool is based on Kouzes and Posner's transformational leadership model, using the Five Practices of Exemplary Leadership as a foundation: Model the Way, Inspire a Shared Vision, Challenge the Process, Enable Others to Act, and Encourage the Heart.16 There are 30 questions that prompt respondents to rate how frequently they use each leadership behavior on a 10-point Likert-type scale. Posner published a review of the reliability and validity of the tool based on studies that used the LPI and a normative database.17 CN participants created an anonymous identification code that could be used to pair responses in self-assessment before and after completing the course. Factors that motivated program participation were assessed through a three-question qualitative survey. This program evaluation was reviewed and approved as nonhuman subject research by the University of Colorado College of Nursing Bridge Committee and the hospital's Quality Improvement Committee with the authority of the Colorado Multiple Institute Review Board at the University of Colorado-Denver. Enriched leadership behaviors There were 12 CN participants who were predominately White (67%) and female (100%), and 58% were 30 to 49 years old (see Table 2). The average range of registered nursing practice was 11 to 15 years, and 92% had less than 10 years of experience as a CN (Table 2). Twelve CNs engaged in the program evaluation project and completed the preintervention LPI, 11 CNs completed the postintervention survey, and 9 surveys were paired for analysis. Unpaired responses were included in the independent t test analysis. Table 2. - Participant demographics (N = 12) Characteristics Participants % n Age 20-29 16.67 2 30-39 33.33 4 40-49 25 3 50-59 25 3 Identifying Gender Female 100 12 Race White or Caucasian 66.67 8 Hispanic or Latin 25 3 Prefer not to answer 8.33 1 Years of RN experience 1-5 16.67 2 6-10 16.67 2 11-15 41.67 5 16-20 16.67 2 21-25 0 0 26-30 8.33 1 Years on current work unit in any nursing role (certified nursing assistant, direct care RN, charge RN, other) <1 8.33 1 1-5 25 3 6 -10 16.67 2 11-15 33.33 4 16-20 8.33 1 21-25 8.33 1 Years in permanent charge RN position <1 33.33 4 1-5 33.33 4 6-10 25 3 11-15 0 0 16-20 0 0 21-25 8.33 1 Primary work shift (more than 50% of time) Days 41.67 5 Nights 50 6 Rotate days and nights 8.33 1 The primary analysis (n = 9 paired surveys) found participants reported an increase in self-assessed leadership behaviors with preintervention LPI scores (M = 210.8, 95% CI [190.5, 231.2]) to postintervention (M = 238.5, 95% CI [216.0, 261.1]) with a mean difference of 23.7 (95% CI [10.1, 37.2]), t = 4.03, P = .004). An independent t test (N = 12) showed similar results, with a mean difference of 32.3 (95% CI [6.5, 58.2], t = 2.6, P = .017). Analysis of the Five Practices of Exemplary Leadership found a statistically significant increase in all domains (see Table 3). Table 3. - Comparison of pre- and post-CNLDWS CN LPI scores Paired t test Leadership Practices Inventory (LPI) scores by five exemplary practices and total score Charge nurse scores Before CNLDWS After CNLDWS Mean SD Mean SD n Differences 95% CI for mean differences t df P ∗ Five exemplary practices Model the Way 45.889 6.698 48.556 5.747 9 2.667 0.393 to 4.94 2.704 8 0.027∗ Inspire a Shared Vision 36.000 9.151 42.222 6.629 9 6.222 0.296 to 12.149 2.421 8 0.042∗ Challenge the Process 40.111 8.343 45.444 7.650 9 5.333 3.060 to 7.607 5.409 8 0.001∗ Enable Others to Act 48.778 3.930 52.889 3.655 9 4.111 1.381 to 6.841 3.473 8 0.008∗ Encourage the Heart 44.111 7.061 49.444 7.264 9 5.333 1.832 to 8.835 3.512 8 0.008∗ Total LPI score 210.833 30.759 238.556 29.305 9 23.667 10.127 to 37.206 4.031 8 0.004∗ Abbreviations: CI = confidence interval; CNLDWS = Charge Nurse Leadership Development Workshop Series; df = degrees of freedom; P = probability; SD = standard deviation∗ = significant Qualitative survey responses revealed that CNs shared similar comments for why they participated in the program. Responses showed a desire for growth in leadership skills for personal improvement and to be better leaders on their units. One participant wrote: “To help in setting up an excellent unit culture, a successful and supported team, and to promote excellent practices on our unit.” The postintervention inquiry about how the program helped CNs on their leadership journey had an overwhelmingly positive response, revealing perceived value of the content and appreciation of the multimodal educational options. Eight participants completed a 45-day postclass survey, with all positively responding that they implemented one thing they learned into practice. After initiation of the course, one unexpected benefit was that some participants requested discussions about career progression, critical conversation planning consultation, and requests for ongoing mentorship from the course leader. The nature of these discussions was very positive and, despite working relationships in some cases, had not occurred prior to the course. Implications for practice The results of this evidence-based leadership skill development program support and expand on current literature. Although the small sample size is a limitation, the positive findings support the work of others.5-8 Krugman and colleagues used the LPI in their longitudinal CN leadership study over the 16-year period, ultimately concluding that CN leadership development contributed to a positive workplace culture.6 LPI scores weren't reported to be paired within the Krugman study; however, exploring paired participant self-evaluation of leadership skill growth builds on that work. The LPI has been used to assess the leadership skills of CNOs in two studies.18,19 The results of this CN program evaluation were similar in how participants rated their leadership behaviors within the Five Practices of Exemplary Leadership.15 The domain Enable Others to Act had the highest mean self-assessment score postprogram.18,19 This demonstrates that nurses with varying degrees of leadership scopes value this domain's key behaviors of fostering collaboration and strengthening others. There was value to the CNLDWS beyond self-assessment using the LPI. Participants reported that learning application of the principles of authentic leadership, improved communication skills, and diversity training were the most helpful. Homer and Ryan also found that communication was valued by CNs as a top skill set to be included in education.4 Diversity training (racial diversity, generational diversity, equity, inclusion, and unconscious bias) topics within the although not specifically in the were important for in CN educational classes. participants that experienced or an with comments made by or The group shared how they the situation and what could be used a When the course, how often with were After the of the the for Nursing Leadership published their for Nurse Leadership to the practice of all nursing leadership This framework diversity, equity, and topics with more than The content taught in the CNLDWS the actions in the framework. diversity training to leaders is essential when the in practice An taught topic that group was about are within a group that are to be Some participants the their unit have rules but their and One participant shared that the had an that the CNs in to the team shift to staff would often in this on their first to be to get of the when the This the up for and shared by the participants to that nursing inclusive This regarding tactics for how the CNs could influence a culture of such as proposed by and colleagues in their of for Inclusion and This to be were Participants found value in the multimodal self-study education to generational for teaching and learning. suggests such as are by and however, and more sources with engaging The postclass learning also participants to be compensated to with the content that without if they not There were educational sent after each class. 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Participants were compensated for attending the and were provided education time for self-paced learning. time to the organization their to professional growth by nurses to become more engaged in their professional development. to the program have been through at the organization to and this pilot program in support of CN leadership skill and there are some to the program. sample size of CN engagement may have provided a understanding of the of the CNLDWS on the CNs' of their skills. The evaluation was limited to the self-perception and a assessment or Finally, although it was by best evidence to leadership skills to the program evaluation was influenced by the organization's culture and The CNLDWS provided support to CNs with diverse of CN leadership will also benefit the organization, unit, and patient The program was by and to professional nursing the of leaders, and the organization's of CNs' daily work. Although the in-person were reported to be essential for of content multimodal learning provided and a model for the program in the CN participants reported that in self-assessed leadership skills after the 4-month leadership course their and The AI framework participants to in personal and an plan for application and implementation of content learned at each class. with the average turnover of per direct care nurse, the per CN participant was per participant or for the The of the course for all CNs is is less than the of turnover for two in leader education and could improve the work and influence staff The CNLDWS is one that can be used as a of ongoing education. findings bring a to the of CN leadership development with for course content and to support the essential role of nurse