Replacing Charge Nurses with Clinical Nurse Leaders in the ED
We’ve seen it happen in hospitals across the country all too frequently - a front-line nursing leadership vacancy occurs and all of a sudden a department leader must scramble to find a replacement. However, like anything is done in haste, finding the right replacement for a role such as the clinical nurse leader has far-reaching implications. In many of the cases we have seen, nurses are slotted into a leadership role due to their unit tenure and/or clinical expertise, not necessarily because they are prepared and/or able to effectively lead.
The role of the unit nurse leader at the bedside often called the charge nurse is important for any nursing unit. When it comes to the emergency department (ED), a high-functioning leader is essential to promoting positive quality patient outcomes, achieving operational metrics, and reducing unnecessary events in the department. For this reason, it is essential that this ED clinical nurse leader have education, experience, and supervisory authority above what most nurses would expect when they hear the term “charge nurse.” Although these leaders replace the charge nurse role to provide continuous 24/7 on-the-unit leadership, expectations of this role far exceed that of a charge nurse. Titles for this enhanced role vary greatly across the US; for the purposes of this article, we will call them the clinical nurse leader (CNL).
The dangers of an ED operating without dedicated CNLs lead to unsolidified professional relationships between that nurse leader and the rest of the staff. It is challenging and unrealistic for staff to supervise a team one day and then function as their peer the next. When this does occur, the non-dedicated charge nurse often focuses on preserving the peer working relationship. As such, performance issues are not addressed, overall team accountability may decrease, and patient care may suffer.
Succession planning is an important undertaking for any successful leader but such planning at the CNL level is often overlooked. Nurses are often selected due to their unit tenure and/or clinical expertise, without regard to their leadership capabilities. But what training have these new nurse leaders been given to succeed in their new role? What proactive leadership development has occurred prior to their selection? Leadership education is key to their success and the long-term performance of the ED.
We recommend the following when implementing the enhanced ED clinical nurse leader role:
Dedicated nurses filling the role:
EDs of all sizes need dedicated CNLs whose primary responsibility is the overall flow of the department. Only in very low volume EDs should these individuals take patient assignments. A dedicated CNL should be on-site 24/7 to oversee flow while providing leadership presence and supervisory authority to ensure real-time issue resolution. In our experience, successful EDs have a dedicated role for the CNL who is not operating in the capacity as a staff nurse with shifting priorities and patient obligations.
Standardization of the role:
Standardization of work and competencies among ED CNLs is essential to promoting consistent operations across the entire department. Staff report the department operates one way when “John” is on-duty and a different way when “Jane” is leading the department. These inconsistencies include differing opinions on how the role is defined, their unique critical thinking skills, a sense of urgency, the ability to delegate, and more.
Span of control in larger EDs:
Larger EDs may require two RNs. In such a scenario, a second dedicated RN, separate from the CNL, should be used to oversee patient flow. In such circumstances, the ED’s volume should dictate the staffed hours for the additional leader. As EDs grow larger, there is a tendency to split the ED into zones, each having their own leader. In such scenarios, the value of having a dedicated on-site CNL overseeing the entire ED is the reduction of siloed processes, inefficient patient care, and potential negative outcomes.
The importance of leadership education:
Exposure to leadership topics, with real-world ED application, is a critical element to a successful CNL position. This can be completed in a variety of ways such as didactic sessions, role playing, and tabletop exercises. At a minimum, these topics should include information educating these nurse leaders on how to:
• delegate
• effectively manage conflict
• effectively communicate through difficult situations
• lead in times of disaster or crisis
• support initiatives of change
• facilitate department throughput
• oversee departmental productivity for their shift
• foster inter-department relationships
• understand risk management (including patient grievances, EMTALA, regulatory readiness, etc.)
• lead a diverse workforce (culture and generations)
• understand the impact of patient experience scores
• decipher all methods of communication (e.g. non-verbal cues)
• know when to intervene (with staff and patients)
• support employees while also holding them accountable
Collaboration with HR partners is essential when designing or restructuring ED leadership team roles. If functioning within a unionized environment, we recommend that the ED CNL role be outside the union to allow them to hold staff accountable and provide real-time coaching.
In our experience, high-performing ED leadership teams share a few key attributes that virtually any ED can implement with the right consistency and dedication to improvement. Nursing leadership, medical leadership, and unit CNLs meet regularly and share a common vision and goals. They pay close attention to quality outcomes and patient satisfaction, develop and implement plans to improve operations (including the review of operational metrics and targets), and establish practice and behavioral expectations while holding the entire staff accountable.
In summary, having a successful front-line ED nurse leader in the department 24/7 is vital to ensuring efficient and effective patient care. Proper succession planning, role specific leader onboarding, role standardization, and ongoing mentoring of these leaders will contribute to improved patient care, increased patient and caregiver satisfaction, improved throughput, and accountable staff.
Nick Chmielewski, MSN, RN, CEN, CNML, NE-BC, FAEN, Senior Consultant at Philips Blue Jay Consulting
Nick is a results-driven healthcare leader with expertise within and outside the emergency department. His experience in opening a startup hospital combined with his project management experience with an informatics overhaul enables him to bring a unique skill set back to the ED.
Larry Faulkner, MBA, BSN, RN, CEN, Consultant at Philips Blue Jay Consulting
Larry is passionate about providing patient-focused care and brings many years of experience in clinical and leadership roles in both urban and rural settings. As an ED director, he has successfully implemented evidence-based leadership tactics including leadership/staff/hourly rounding and bedside shift reporting.