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The Role of the

Charge Nurse
WHAT I BELIEVE IT TO BE, WHY I AM HERE AND WHAT I COULD OFFER TO
THE ROLE
What is a charge nurse and how
has this changed over time?
The position of charge nurse is defined by the RCN as a profession through which a senior nurse is
responsible for the care of patients and supervision of staff on a particular ward.
Traditionally, this post has often been referred to as a ward sister, but due to its potentially sexist
undertones, has been gender neutrally re-assigned as a charge nurse.
Although people have suffered with physical and mental illness for as long as history dates back,
nursing was not a formal profession until the First World War (Nursing History, 2012).
Care for those with mental illness was formalised in 1885, with the publication of "Handbook for
Attendants of the Insane", with the role changed to nursing in the 20th century (Stockwell, 2008).
In the hierarchy of nursing and healthcare, the position of charge nurse is supportive upwards
(management) and downwards (staff nurses, healthcare assistants and students).
However, the perceptions and expectations of the job itself have changed dramatically over
time.
Hinkle and Hinkle (1977) defined the charge nurse role, as overseeing
patient care, providing complete documentation and managing staff
interactions.

In this era, those in positions of power such as charge nurses, with thanks to
literature such as "One Flew Over the Cuckoo's Nest", were seen as
enforcers of treatment, neglecting the human element of nursing.

Healthcare has evolved since this, due to an ever changing social and
economic dynamic, with advances in psychological interventions and
greater knowledge into mental illness.

The charge nurse is now an advocate for high quality service user care and
a practitioner who uses their knowledge and experience to support staff to
improve their practice, whilst enhancing the therapeutic potential of service
experience and managing an increasingly complex risk picture.

The needs of the role necessitate that those within it have adequate
educational, practical and emotional development to prevent role
confusion, high work stress and decreased effectiveness of the ward
environment (McCallin and Frankson, 2010).
Why do acute wards need charge
nurses?
The acute inpatient environment is one of constant change and pressure and there
is increasing demand on its resources which correlates with decreased resources in
the community setting.
This can make working in such a place an extremely stressful experience, which if
not properly supported and managed can have a negative impact on service user
care and by proxy the levels of risk to staff, service users, carers and the public.
As such, charge nurses form a vital part of this system and are the mediaries
between staff and those in their care, acting at times as a buffer in difficult
situations (RCN, 2009).
There is extensive research evidence which links the presence of the charge nurse
in acute settings with patient outcomes and hospital safety (Hay Group, 2006).
From my experience of working on an acute admissions ward, charge nurses are an
integral part of the ward team and without them we are unable to offer the high
quality care we do.
So, what does literature suggest are the
role aspects of the charge nurse?
Eggenberger (2012) described 7 elements to the role,
that those in the position have a responsibility to:
A) Keep patients happy
B) Create a safety net
C) Monitor for quality
D) Show the way
E) Complete the Puzzle
F) Manage the flow
G) Put out fires
( metaphorical fires and I'm sure given where we work, some actual fires).
So what does this mean in practice?

Keeping patients happy is much more complicated than it sounds, as unfortunately


cake does not in fact make everything better.

In the acute setting, patient satisfaction is monitored throughout admission and on


discharge through interactions and questionnaires.

Happiness and feeling safe on the ward are often linked with adequate staffing and
effective shift/Rota planning, of which a charge nurse is responsible, accounting for
the needs of the ward and needs/requests of the staff team.

Baillie (2007) emphasised the importance of acting and promoting others to act in
a way which prioritises patient dignity, through the use of humour, compassion and
empathy.

This encompasses appreciating and respecting culture and diversity and providing
education around sensitive and person centred care.

As a charge nurse, the role Is to champion a recovery based approach, which


involves service users and their carers in their recovery and using your knowledge of
both them, the resources available and clinical perspectives use their admission to
find the best possible outcomes in terms of safety and quality of life.

This involves liaising with community services and formulating effective plans to meet
their needs both in and upon leaving hospital (RCPsych, 2011).

As a charge nurse, there are many opportunities to achieve this, on day to day
ward interactions, through Mdt duscussions, interface and liaison and referral to
Carer's Gloucestershire.

It is about listening to service users and staff concerns about elements of care and
addressing these appropriately.

It is also related to understanding what makes a therapeutic ward environment,


recognising threats to this and through effective team work minimising these, using
access to bed managers and hospital resources to ensure admissions are
appropriate and that the needs of all service users are considered in risk assessment
and care planning.
Creating a safety net is a part of this, using experience and knowledge as a charge nurse to look at alternatives
and use these appropriately, referring to alternative units more suited to manage the risks and needs of those in
our care if needed. However, the safety net also applies to how you are seen by members of the team, it is
about being available as a safe place to air concerns and seek support.

It is about using your links with community teams to look at options upon discharge and liaising with local police
when safety concerns arise about someone not present on the ward or not manageable/appropriate for mental
health services and supporting advising the ward team in making these decisions.

In terms of monitoring for quality, West et al (2002) highlighted the link between ensuring practice is monitored
and supported and lower patient mortality and as part of the Fair a Deal Campaign Manifesto, regular
supervision and being active in ensuring good practice improved rapport with staff and strengthened team
work (RCPsych, 2008).

As a charge nurse on the ward, this is managed through being present and aware of hospital situations and of
individual situational difficulties and addressing these in a professional capacity.

Showing the way refers to the need to be visible and accessible to staff needing support or advice/information
when needed (RCPsych, 2010) and as a part of this informing others of new or changed policies and auditing
the implementation of these, needing to have a good knowledge of required information and determining what
is required and how to access it at a given time.

In short, a charge nurse should champion a culture of learning and quality improvement (NHS, 2010).

Completing the puzzle as a charge nurse requires the person to collect and collate information pertinent to a
situation of service user, involving carer's, looking at someone's history and continuing the Mdt process , utilising
pharmacy, medical and cultural assets to create truly person centred care with your team and helping them to
access these. It is also about yourself as a part of this puzzle, the piece that is needed for effective running of the
shift and ward environment and knowing how to do this.

To manage the flow, a charge nurse must consider what is required for the operation of their patient area and
support staff on a shift by shift basis to deal with the demands placed upon them, which often alter, frequently
prioritising and deciding the order in which tasks need to be completed, without taking over completely and de-
skilling or impeding staff.

Putting out fires is something we know unfortunately a lot about at Wotton Lawn, both in the physical and
metaphorical sense and for the charge nurse it is about ensuring a safe environment, dealing with issues as they
arise and preventing harm where possible to all involved in care. Furthermore, the role requires that you support
recovery from burns and rebuild stronger plans/systems afterwards through assessing an analysing their triggers
and accelerants (RCPsych, 2010). The Safewards Initiative is a useful tool for the charge nurse in supporting the
minimisation and management of conflict to reduce the risk of harm.
So what else can the role of a
charge nurse possibly be???
Berbarie (2010) stated that the role also requires
charge nurses to be celebrators of those they work
with.

A charge nurse should not only support good


practice, but show appreciation and praise when
this is completed.

At times, working in the environment we do can feel


like a thankless and all consuming job, decreasing
morale and job satisfaction.

Celebrating the achievements of the team and


individuals within it increases the feeling of control
and value to the service .

This in turn is shown to reduce burnout and sickness


(Carrim et al, 2006).

This could be as simple as saying thank you at the


end of a difficult shift or advising management of
their help.
Other perspectives on the charge nurse role

Similar to Eggenberger's conept of "showing the way", Berbarie cited the


charge nurse as an agent of change, who should encourage innovative
thinking and challenge stigma and negative attitudes, both within the team
and in their service setting.

It is about anticipating and managing blocks to this, such as staffing resources,


bed management and role ambiguity, supporting staff to maximise the
potential of their roles and capabilities.

A charge nurse should engage in and encourage reflective practice, which


uses the most up to date and relevant research and information to influence
practice.

The role should involve supporting staff to deal with work related anxieties and
be a source of consistent support, reassurance and advicebin situations such
as serious incidents or changes to work conditions which are outside the
control of frontline staff (Brennan et al, 2006).

These changes should involve innovation, which is discussed with the ward
team and uses the shared experiences and skills of the team to improve
outcomes.

Finally, Berbarie cited charge nurses as "financial stewards", responsible for


managing budgets alongside team needs and utilising resources effectively
and efficiently. This can be a challenge, due to current staffing issues and
meeting NICE guidelines for safe practice. As mentioned earlier, the charge
nurse must use both common sense and resources to plan shift staffing through
rotas and adapt these as the demands change, assessing the need for
additional staffing based on clinical need.
The Key Aspects of the
Charge Nurse Role:
Blake and Young (2015) simplified the role into 4 key aspects and skill sets required:

1) Leadership, broken down into 5 defining elements: challenge the process, inspire a
shared vision, enable others to act, model the way and encourage the heart (Kouzes
and Posner, 2011).

Although charge nurses are not the team leader, there are times when they are needed
to fulfil that role and act as the person in charge. Situations such as being the on call
band 6 during unsocial hours or holidays leave the charge nurse with not only responsibility
for their ward, but also as a source of authority and support for the wider hospital, liaising
between wards and community teams and supporting staff through difficult situations.

Hunter (1998) defined leadership as "an authority based on love, sense and sacrifice,
strengthening the bonds of respect, responsibility and caring for those you work with".

To be in this position, you need to genuinely care about the wellbeing of your team and
the environment you work in and through transformational leadership, inspire others to
have mutual interest in supporting each other to improve practice.

Being a charge nurse is not a different role to being a staff nurse, it is an expanded role
and as such you should never expect members of your team to take risks you would not
be willing to. You are not a superhero making decisions for the team. You are a team
member, helping the team to make decisions for the good of all.

A charge nurse should be a role model and set an example with professionalism and
dedication to the team and the job and via this, create a positive and productive work
environment.
2) Communication- Charge nurses should create an
environment, which fosters open and respectful
communication, building on trust.

When teams do not communicate effectively, this puts staff and


service users at risk and increases the risk of errors.This can be
effected if there is a hierarchical dispute (Hughes, 2008).

This requires that the charge nurse does not set themselves
above the team, needing to be supportive and non-
threatening.

However, the charge nurse still needs to be assertive in areas of


clinical importance, but ensuring that assertive does not
become aggressive or 'bossy' is vital.

Making sure the team understand that their experiences,


opinions and knowledge are valued during interactions is
central to keeping communication flowing, even when
differences of opinion are present.

Charge nurses must be adept in active listening, suspending


judgement and containing personal emotions in considering
the input of others and subsequent decision making.

Listening increases knowledge, generates ideas, builds


relationships, exhibits respect and builds teamwork, all vital to
the role of charge nurse.

Effective communication establishes and promotes professional


competence and higher quality patient care.
3) Conflict resolution- this is more than we are taught in 2gether training and refers to
more than de-escalating a service user in an agitated state.

Whilst the role of the charge nurses still comprises of active involvement in this area, at
band 6 level you have a responsibility to manage staff and hospital disputes before
they impact on patient care.

This can be supporting the ward team in arguing against an inappropriate admission
or when on call, mediating a dispute about patient care.

At times, the conflict can be between staff members, which may be driven by ward
stressors, interpersonal differences or unprofessional conduct.

In any of these scenarios, it is important to remain calm and professional, adapt


answers and solutions to the situation and to tactfully deal with the problem early
(Johansen, 2012).

As a part of this, the charge nurse will also have to consider the validity of the
complaint/dispute and whether there is a need to seek help from superior
management or if serious enough, to speak with regulatory bodies.

As a band 6, it is also a part of the job that in some of these situations you will be a part
of the conflict, but as described above the same management strategy should apply.
If it surrounds an aspect of your practice, it is your responsibility to assess your own
competencies, reflect on your actions, speak with your supervisor and alter your future
actions

In an acute hospital setting, the high pressure nature of the environment means that
conflict is more likely to occur, but the severity and frequency of these can be
influenced by the charge nurse if they use their skills and experience intelligently and
consider carefully how any decision will affect the team and the service users.
4) Delegation- something done throughout the ranks of
nursing, but expanded in the band 6 role.

This is one of the most important management skills, as


efficient delegation enhances the rate and quality of
important items achieved and builds a sense of shared
responsibility and respect in teams.

Chapman (2015) explains that successful delegation is


SMARTER, an acronym to summarise how to delegate.

It states that delegation should be specific, measurable,


achievable, realistic, time managed, ethical and recorded.

It is the role of the charge nurse to delegate tasks based on


an individual's competencies and experience and be within
the legal and ethical framework for practice.

Standing and Anthony (2006) describe delegation as vital in


acute care settings due to the high demand upon staff and
as the only way to "get things done".

As a charge nurse, your role is also to support staff with tasks


and be present to offer advice and assistance where needed
and give feedback afterwards, interlinking with the role of
monitoring and celebrating practice.

Even Nelson Mandela famously once said, "no single person


can do everything" and experience suggests this to be very
true.

Furthermore, denying team members the opportunity to share


the work load is undermining, patronising and insulting to their
abilities.
Personal qualities required to be effective in the role
From my experience as a mental health nurse working with excellent charge nurses and
reviewing literature, there appear to be 5 central themes in being an effective charge
nurse, in relation to displayed characteristics.

Firstly, a charge nurse, especially on an acute admissions ward must be resourceful,


which as Blake and Young clarify, is not having all the answers, but knowing where to
find them.

This involves having a good understanding of the ward and hospital assets, whether that
be staff and their abilities, medications for emergencies such as rapid tranquillization of
dystonic reactions or the bed States of other wards and using effective communication
to access these.

Sometimes there is no avoiding an admission, even when you are a staff member down,
have someone on 1:1 and 10 people on escorted leave who are all heavy smokers.

The resourceful charge nurse will know that it is unsafe to try and manage all these areas
without extra support and will seek support from around the hospital whilst the admission
takes place and still offer support to the team on shift, directing them and delegating
appropriately.

Secondly, as described in earlier slides, an effective charge nurse displays excellent


communication skills, with all levels of healthcare and even in conflict can manage the
anxieties of the team and themselves, at times saying things others can not.

They are the point of reference when a difficult conversations need to be had within
teams, service users and their families, to allow the staff nurses to continue their
therapeutic relationship with service users, unfortunately at times, they become "the bad
guy".
Qualities continued
An effective charge nurse is also decisive and flexible, adapting to an
ever changing environment and at each stage considering the needs
and risks associated with decisions made, in a prompt manner.

For this, there must be confidence of the person's abilities from the team
and within, but also confidence in the teams capacity to meet the
requirements placed upon them through the decision.

The charge nurse should have a good understanding of what effects


individual team members and have strategies in place to deal with any
issues arising from these.

As part of this, the charge nurse must be aware of the big picture,
anticipating the implications for all involved and considering all
influencing factors, from policies to person centred factors and staff
history in similar scenarios.

They should know about important changes likely to affect the inpatient
environment in the 2Gether trust, such as potential for shift pattern
changes and pay review, which may cause increased stress for team
members and be able to offer some answers and reassurance about
the same.

This extends to government policy, changes to benefits or prosecution


under the law, safeguarding procedures and decrease in access to
substance misuse services or community recovery projects.
And some more An effective charge nurse should also be clinically competent, with a wide skill
qualities base and relevant training. They should work within the NMC code of conduct
and be able to recognise practice, which does not.

This is to be a useful source of support and advice for team members, to


recognise signs of anxiety and burnout and be able to offer help.

Knowing when to step in and being able to assess the point at which offering
support or advice, or intervening is necessary and not smothering, enhancing staff
abilities and skill development, not regressing or hindering.

This is especially important for the experiences of students and newly qualified
nurses, who need extra support as though they may be clinically excellent,
intelligent and compassionate, they are often unprepared for the physical and
emotional impact this career will have on them.

Lack of support and inadequate human resources can lead to disillusionment


and is one of the main reasons for newly qualified nurses leaving and students not
returning (Twibell et al, 2012).

This links in with the need for charge nurses to be approachable, staff should see
them as safe to speak with and in turn should be made to feel valued and
understood. Some things can be difficult and distressing to speak about and often
the fear of consequences can prevent someone from seeking help. A charge
nurse must be present and motivated to care for the interests of their team and it
be clear within the environment (Sherman et al, 2011).

Again, this is connected to someone's team leadership skills, intrinsically


motivating others to act, driven to make the team work (Kalisch et al, 2009).
Just a few more, I promise
To be effective within the role, a charge nurse
should be competent in managing organisational
and personal demands.

This is to be able to work within the parameters of


the 2Gether framework, with a working knowledge
of the ward operational policy and to have a
passion to learn and improve services and practice.

To do this, the individual must be capable of


clinical, critical thinking (Connely et al, 2003), using
problem solving and empathy, demonstrating self-
awareness and empathy, able to see how your
actions may influence events and interactions and
weighing up the cost/benefit of these.

The way in which decisions and actions are


formulated should be driven by the 6 C's: care,
compassion, competence, commitment, courage
and communication.

Again, these are present at all levels of healthcare,


but remain as important at a band 6.
The role of the charge nurse in risk
management and the SI process.
Although band 5 staff nurses are usually the writers of and involved in risk
management plans and immediate reassessments of risk and risk taking, the
charge nurse is responsible for supporting staff in this and ensuring they meet
the standards required and that they provide contingency plans should the
need arrive.

Ensuring policies are widely known and practice influenced accordingly is


integral to safe practice and so far from reviews, it appears that our trust and
as such our wards have good adherence to these ("rapid tranq"- Chiudhury
et al, 2010).

Research suggests that the rate of violence is linked with staff attitudes and
behaviour, so as a charge nurse it is important to influence and advocate
practice likely to minimise the risk, ensuring ward staff have relevant conflict
resolution and Pmva training and monitoring attitudes around restraint within
the team.

Any serious incident, be it suicide, assault or death has a serious impact on


the staff involved and it can be just as traumatic as for service users, but as
staff we are expected to continue, to carry on.

A band 6 should be there to debrief and assess the actual impact and
locate appropriate support and information.

Models such as "Safewards" should be utilised and theories from these used
to inform practice,
Potential challenges to the new
band 6 and how to address them:
Challenges Solutions
The band 6 role comes with increased Seek advice and support from senior charge
expectations and responsibility, which may nurses and ward manager and use
be difficult to adapt to. feedback from team members to improve.
Being viewed as inexperienced and as such, Accept that I am new to the role, but show
opinions of less validity. through practice and knowledge my
abilities.
Increased pressure leading to increased
anxiety and the risk of falling into stress driven Make team aware of signs of anxiety so they
habits (bossiness, mothering). are not misconstrued and reflect with
supervisor about ways to recognise signs
earlier.
Being thrown into new situations and not Think about own experiences, seek advice
having all the answers. from others and learn from this.
Having to deal with unprofessional Utilise conflict resolution techniques and offer
conduct/staff conflict. a neutral opinion to both/advise about
proper practice and liaise with others where
necessary.
Why I am interested in the role and
what I can offer. In terms of what I could offer to the role, I'm
dedicated to providing high quality care and
improving practice.

I have been a qualified band 5 staff nurse for almost I am a team player and believe emphatically that a
4 years and had the privilege of working on Priory strong and supported team can overcome
ward for all but 6 months of this. anything that might be thrown at us.

I have loved every minute of my time, even when I am hard working, compassionate, resilient and
there were shifts that were emotionally draining and always aim to see the strengths in people alongside
exhausting I have never once genuinely questioned the difficulties and like to work in a solution focused,
my career choice. problem solving way.

The ward team, although constantly in a state of I have a wide practical and academic knowledge
change, are fantastic and I am incredibly lucky to of mental illness and the acute ward setting,
be a part of it. including risk management, positive risk taking and
medication guidelines.
In that time, I have lived independently, become a
mother and seen every imaginable situation at I can relate to staff at all levels and care about their
work. experiences and opinions and want to continue to
be an active part of collaborative ward work.
These experiences have Increased my knowledge
of mental health and the requirements who work I am eager to learn and willing to adapt to the new
within its settings. challenges and environment.

As a result, I am driven to advance my nursing I would look at innovative ways to improve the
experience and use this to improve experiences for therapeutic potential of Priory ward and drive for
service users and the staff team. person centred care.
Closing gratitude and apologies.

I would just like to say, regardless of today's outcome that I am extremely


grateful for the opportunity to be considered for this role and whatever the
decision, I will continue to aim to deliver the highest quality care I am able,
within a fantastic nursing team.

I apologise if there was a lot of waffling during this presentation, but I find
interviews a very difficult process and increased visual prompts help me to
express what I would like to say.
Thank you for listening.
What I aim to achieve if successful
If successful, I would aim to continue
working with the Priory ward team and
offer the additional support I would be
able to as a charge nurse.
I would use evidence from research and
guiding principles and policies to influence
the practice of staff on the ward.
As I am very interested in the
management of people with personality
disorders in an acute setting and have
seen first hand the varied results with
current strategies, I would like to use my
role as link worker to look at new ways of
working with them and look at
implementing these on the ward.
I would also continue baking a lot, so I
apologise in advance to anyone
watching their waistline.
Kalisch, B., Weaver, S., and Salas, E. (2009). What does nursing teamwork
look like? A qualitative study. Journal of Nursing Care Quality. 24(4). Pp298-

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