Running head: THE EFFECTIVENSS OF A CHARGE NURSE LEADERSHIP 1

The Effectiveness of a Charge Nurse Leadership Development Program on Nurse Retention

Gary Allen Parker

Jacksonville State University

Department of Nursing

Chair: Dr. Douglas Stephens

Date of Submission: July 19, 2019

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Table of Contents
Abstract……………. .......................................................................................................... 4

Introduction ......................................................................................................................... 6

Background ......................................................................................................................... 6

Problems Statement ................................................................................................... 8

Organizational Description of Project Site ................................................................ 8

Review of the Literature (related to evidence-based practice/s to address the problem ..... 9

Evidence-Based Practice: Verification of Chosen Option ................................................ 14

Theoretical Framework/Evidence-Based Practice Model ................................................ 15

Objectives & Outcomes .................................................................................................... 19

Project Design ................................................................................................................... 20

Project Site and Population ................................................................................... 21

Setting Facilitators and Barriers...................................................................... 21

Implementation Plan/Procedures ...................................................................................... 22

Measurement Instrument(s) .................................................................................. 22

Data Collection Procedure .................................................................................... 22

Data Analysis ........................................................................................................ 22

Cost-Benefit Analysis/Budget ........................................................................................... 24

Timeline… ........................................................................................................................ 25

Ethical Considerations/Protection of Human Subjects ..................................................... 25

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Conclusions ....................................................................................................................... 26

References.. ....................................................................................................................... 28

Appendix (All inclusions are listed sequentially in the order they appear in the paper) ......

Appendix A ........................................................................................................... 32

Appendix B .......................................................................................................... 33

Appendix C ........................................................................................................... 34

Appendix D ........................................................................................................... 46

Appendix E ........................................................................................................... 47

Appendix F............................................................................................................ 48

Appendix G ........................................................................................................... 49

Appendix H ........................................................................................................... 50

Appendix I ............................................................................................................ 51

Table 1……………………………………………………………………………52

Table 2……………………………………………………………………………53
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Abstract

BACKGROUND: A large metropolitan hospital in the southeastern United States has delivered

advanced, high quality medical and surgical care to patients for almost half a century and nurse

retention is critical to this organization’s success. Within 2018, the overall Registered Nurse

turnover percentage steadily increased from 16% to above 20% by the end of the year. In 2018,

this facility spent $1,061,214 as a result of turnover. A Charge Nurse Leadership Development

Program must be designed to help reduce the Registered Nurse turnover percentage to positively

impact patient safety, quality of care, and patient experience.

METHODS: Eleven charge nurses from two separate medical-surgical nursing units with over

one-hundred thirty years of combined experience attended a sixty-minute workshop where a

presentation was led by the creator of the Charge Nurse Leadership Development Program. The

following topics were discussed during the presentation: Effective communication, collaboration,

decision making, problem solving, the importance of creating a unit vision, performing research

development activities, the importance of being more knowledgeable regarding policies and risk

management, team building exercises, conflict management, supervision and delegation, how to

manage the behaviors of others, creating a healthy work environment on each unit, and the

importance of mentoring new staff members for enhanced overall success.

RESULTS: The Oncology Medical-Surgical unit saw a decrease in Registered Nurse

resignations immediately after the Charge Nurse Leadership Development Program and has

sustained zero resignations per month for three consecutive months. The Medical-Surgical unit

had one resignation per month for the following three months after initiation of the Charge Nurse

Leadership Development Program. When evaluating the Registered Nurse head count, the
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number of nurses on both units stayed consistently between twenty and twenty-five nurses for

the time period in which the data was gathered.

CONCLUSION: The Medical-Surgical unit consistently for three months in a row managed only

one Registered Nurse termination per month. After the Charge Nurse Leadership Development

Program, there has not been a month which resulted in greater than one resignation per month,

whereas in August 2018 there were two resignations in one month. Unfortunately, consistent

staffing levels were not able to be maintained on this unit due to high census through the late

2018 and early 2019 which could have led to the resignations. On a regular basis, the Medical-

Surgical unit staff had seven and eight patients per nurse during the data collection period,

whereas the typical prior to the implementation of the project was five to six patients per nurse.

The Oncology Medical-Surgical unit had great results from the Charge Nurse Leadership

Development Program and has sustained zero resignations from December 2018 through March

2019. Consistency with staffing ratios and excellent buy-in from staff members on the Oncology

Medical-Surgical unit has ensured success with the program. This study would benefit from the

collection of data for an additional three to six months to gain clarity on the effectiveness of the

project.
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The Effectiveness of a Charge Nurse Leadership Development Program on Nurse Retention

Introduction

Nursing turnover has a tremendous effect on the operations of healthcare organizations,

as it can limit opportunities for these facilities to receive admissions and offer services, impacts

the quality of care given and negatively impacts patient satisfaction. Employee turnover is a key

metric and performance indicator when evaluating the fiscal and operational effectiveness of any

healthcare facility (Kurna-Thoma, 2017, para.1). The national average turnover rate on the rise

verified as hospital turnover is 18.2% with medical-surgical, stepdown, and emergency care

experiencing the highest rates (Nursing Solutions, 2018, para.1). There are two medical-surgical

units at a large metropolitan hospital in the southeastern United States that each have a twelve-

month rolling nursing turnover percentage greater than the national average. Ensuring that nurse

retention is a focus and interventions are in place to decrease turnover is imperative for

organizations and especially these two medical-surgical units. This project will focus on the

impact of a Charge Nurse Leadership Development Program’s influence on Registered Nurse

turnover rates within these two units.

Background

A large metropolitan hospital in the southeastern United States has delivered advanced,

high quality medical and surgical care to patients for almost half a century. Patient safety, quality

of care, and patient satisfaction are dependent on nurses and the frequency in which they leave

their nursing positions is critical to an organization’s success (Rosenbaum, 2018, para.5).

According to a study by NSI Nursing Solutions, the turnover rate for bedside Registered Nurses

in 2016 was 14.6% and has increased to 20.6% in 2017 (Rosenbaum, 2018, para.5). Within 2018,

this facility experienced Registered Nurse turnover percentages steadily increasing from 16% to
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above 20% by the end of the year, which is three percent higher than the division average.

Special attention must be allocated on Registered Nurses that have been with the facility less

than one year as with this specific population; the turnover percentage was 33.9% in August

2018. This organization must place focus on retention of nurses as the average cost of turnover

for a bedside Registered Nurse is $49,500 (Nursing Solutions, 2018, p.1). In 2018, this facility

spent $1,061,214 as a result of nursing turnover. The evaluation of this organization’s Registered

Nurse attrition rate compared with the Southeast region (AL, FL, GA, KY, MS, NC, SC, TN, VA,

and WV), revealed this facility sustained a 5% higher attrition rate (Nursing Solutions, 2018,

pg.8). Acute care, for-profit facilities in the United States have a lower turnover percentage by

2.8% (Nursing Solutions, 2018, pg.8). This facility has a significantly higher turnover

percentage, 3.4% higher than other facilities with a similar bed capacity of 200-349 beds

(Nursing Solutions, 2018, pg.8).

Reasons that nurses leave their current position must be evaluated. According to a survey

which asked Registered Nurses who voluntarily terminated or changed employment status from

full-time to as-needed (PRN) within a nine-month period, the most common reason that

Registered Nurses change their positions is due to hours worked (Strachota, 2003). Hours

worked may include many contributing factors such as: Working long shifts, overtime, weekend

shifts, night shifts, holidays and scheduling issues (Strachota, 2003). Staffing levels,

management support, decreased quality of care, stress, and relationships with coworkers are

additional reasons for nurses changing positions (Krukow, 2003). Charge nurses must be aware

of the issues that are contributing to staff leaving their positions so that change can occur.
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Problem Statement

To ensure that the hospital can continue to provide services and deliver high-quality care,

this facility must take immediate action to reduce the attrition rates and the high cost associated

with turnover. This program will seek to determine if there is an impact of a Charge Nurse

Leadership Development Program on increasing retention of Registered Nurses compared with

units that did not participate in the program. With twelve-month rolling turnover percentages

above the national average and prodigious costs over the past year due to nursing turnover, there

are specific two units that would benefit from a program with specific attention devoted to the

retention of nurses. A presentation will be scheduled for the combined eleven charge nurses on

the Medical-Surgical unit and the Oncology Medical-Surgical unit with the focus on informing

of the issue and the impact that each of the charge nurses can potentially have. Aspects of a

positive working environment and an improved focus on mentoring new nurses will be addressed

during the presentation to show the benefits that it can have on Registered Nurse retention. For

three months after the presentation, turnover data will be analyzed to see the effects.

Organizational Description of Project Site

A large metropolitan hospital in the southeastern United States has two units, a Medical-

Surgical Oncology unit and a General Medical-Surgical unit, that would be ideal for participating

in this project due to the high turnover percentage and consistency in leadership. Medical-

Surgical units are an ideal population to study due to the high incidence of turnover commonly

reported. The Oncology Medical-Surgical unit has a Registered Nurse rolling twelve-month

turnover percentage of 18.5%, and the General Medical-Surgical unit has a rolling twelve-month

turnover percentage of 29.9% with an overall nursing turnover percentage of 20.3% for the

facility. The combined years of experience for the charge nurses on both units is 131.5 years with
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 9

the average years of experience for the charge nurses equaling near twelve years per charge

nurse. This facility is ideal to study since its location is in the Southeast region of the United

States, the second highest in turnover percentage by region (Nursing Solutions, 2018, pg.8).

Review of the Literature

Nursing Turnover

One can describe nursing turnover as voluntary or involuntary, avoidable or unavoidable,

internal or external; however turnover, in general, has a negative impact on an organization

(Halter, 2017, pg.824). According to Halter, six areas contribute to turnover: When nurses had

fewer possibilities for development or professional growth, management by exception, autocratic

leadership, low-quality teamwork, stress and burnout (Halter, 2017). Level three studies found

incredible statistics related to nursing turnover. In the United States of America, it was found that

35% of newly graduated nurses left their place of employment within one year, while 57% left

within two years (Duffield, 2010). Nurses working on units with high turnover tend to report

higher stress levels as they may be called on to cover vacant shifts and to participate in the

constant training and induction of new staff (Duffield, 2010). Numerous decisions were

discussed as the top reasons for nurses leaving their jobs that included: Patient acuity, increased

workload, ineffective working relationships among nurses and physicians, and lack of leadership

support (Hayward, 2016). Turnover contributes to increased recruitment and orientation costs,

reduced quality of patient care and the loss of mentorship for new nurses (Hayward, 2016).

Research, level five studies, have shown that there is a statistically significant relationship

between leadership style and staff nurses’ intent to stay with an organization and that nurses do

not leave hospitals, they leave managers (Swearingen, 2009, p.107). Nursing leadership affects

staff retention, patient outcomes, retention and recruitment of the nursing workforce, the delivery
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of patient care, and the financial stability of a health care organization (Swearingen, 2009).

Organizations will find it essential to reduce nursing turnover due to the significant negative

effects that it can have on performance.

How to Retain Nurses

According to level one evidence, a leader must offer praise and recognition, utilize a

transformational and participative managerial style, develop group cohesion, and offer supervisor

support (Halter, 2017). The ability to retain nurses gives an organization either an advantage or

disadvantage in the healthcare market. Retention, according to level three evidence, has been

linked to positive outcomes for hospitals to be able to keep their highly qualified Registered

Nurses and is tied to healthy work environments and best practices (Ritter, 2011). The link

between a healthy work environment, nurses’ satisfaction, and increased retention rates have

been noted by various researchers (Duffield, 2010). An efficacious nursing unit manager who

consults with staff and provides positive feedback is instrumental in increasing job satisfaction

and satisfaction with nursing (Duffield, 2010). The following five essential factors regarding

nursing leadership have been associated with higher levels of staff nurse satisfaction and

retention: Visibility, recognition, being a good leader, flexible rostering, and consultative

leadership (Duffield, 2010). Effective nurse leaders are providing opportunities for open

discussion, considering the ideas of others, being available, maintaining high standards of

performance, instilling pride in the workplace, and promoting healthy relationships between staff

members (Duffield, 2010). There is a significant agreement between studies concerning factors

that contributed positively to job satisfaction, and they include the professional role, respect and

recognition from clients and managers, workplace recognition, autonomy, access to resources,

and the flexibility of the position (Halcomb, 2018). Attractive hospitals have many of the
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features of healthy workplaces, are less hierarchical, and benefit from high levels of trust

between workers (Stordeur, 2006). Attractive hospitals have a distinctive profile characterized by

intentional, systematic and collaborative efforts to maximize employee well-being by providing

well-designed and meaningful jobs, a supportive socio-organizational environment and

accessible and equitable opportunities for professional development and work-life enhancement

(Stordeur, 2006). Swearingen states in a level five evidence article, that the best way to retain

staff is to give leaders the knowledge needed to create a work climate that motivates and engages

employees (Swearingen, 2009, p. 107). The better the staff’s perception of their leader, the

greater their intent to stay with the organization (Swearingen, 2009, p. 107). Lower turnover

percentages for organizations can be an indicator of an attractive facility to be employed by and

have many distinguishing characteristics. The ability for organizations to retain staff and

especially nurses will impact their overall success not only due to the costs involved but with the

impact on patient care.

Learning Needs of Charge Nurses

Leadership skill development of primary interest include communication, relationship

management, delegation, conflict resolution, problem-solving, planning, and decision making,

according to a level one evidence article (Darragh, 2016). Level three evidence states that

leadership development needs to be a priority and organizations must create settings that promote

this development (Wojciechowski, 2011). Charge nurses consistently feel unprepared for their

role (Delamater, 2018). Charge nurses when unprepared to assume the leadership role can bring

about a problematic situation because of their inability to adequately supervise staff, maintain

appropriate standards of care, and ensure professional staff and patient interactions

(Wojciechowski, 2011). Without a continued commitment to and involvement in nursing

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leadership development for executives, managers, front-line leaders, and staff; the future of our

healthcare organizations will be at risk (Wojciechowski, 2011). According to twenty-two charge

nurses, the top three learning needs that would help the charge nurses perform in their roles are:

Developing leadership skills, managing behaviors of others, and creating a healthy work

environment (Wojciechowski, 2011). Charge nurses also need five critical skills and they

include: Communication, supervision, delegation, conflict management, and team building

(Wojciechowski, 2011). Five out of nine studies identified communication as the primary charge

nurse leadership trait (Delamater, 2018). Managing teams is the second most overall leadership

skill consistently seen throughout the studies which include specific skills such as teamwork,

collaboration and guiding others (Delamater, 2018). Other leadership skills necessary to add in

the Charge Nurse Development Program are conflict resolution, delegation, healthy work

environments, and service excellence (Delamater, 2018). According to over twenty-four hundred

nurses, the most important leadership characteristics of the front-line nurse manager or charge

nurse include visibility, accessibility, consultation, recognition, and support (Duffield, 2010).

Charge nurses impact patient care and outcomes; however, they need to fully develop their

leadership skills to reach their maximum potential as front-line leaders (Delamater, 2018). Level

four evidence gives great insight on the which skills charge nurses need to acquire and how

charge nurses prefer to learn. Charge nurses need to acquire the skills to navigate increasing

patient acuity while maintaining interdisciplinary team relationships and managing unit morale

(Thomas, 2012). Charge nurses prefer learning new information via computer-based education as

well as learning in the classroom setting, however not all prefer the computer-based education

(Sandeep, 2017). Best practice recommendations for developing charge nurses include having

the charge nurse attend a formalized structured education program to empower them to help
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increase their confidence in decision-making, increase their engagement in unit functioning and

activities, and enhance their leadership skills (Sandeep, 2017). Findings suggest that content

must be relevant to the charge nurse role and delivered in shorter segments of time.

Organizations must emphasize the development of the charge nurses to ensure that they feel

equipped for the role and have the tools and knowledge to handle difficult situations.

Leadership Classes and the Importance

Charge nurses have a tremendous role in reducing nursing turnover and retaining

Registered Nurses. The role of leadership, from a level one evidence is to inspire, encourage,

influence others in a manner that keeps them committed to the goals and values of an

organization (Darragh, 2016). A lack of a formal orientation process, mentors and ongoing

support may impede charge nurses from fully developing in their role (Darragh, 2016). A level

three article mentions, as stated in their titles, the charge nurses are “in charge” of the specific

nursing unit, and they represent the leadership part of the nursing team on the unit,

(Wojciechowski, 2011). Charge nurses can inspire and motivate staff to perform beyond basic

expectations and can enhance a sense of team spirit across the nursing unit on all shifts

(Wojciechowski, 2011). Leadership is defined from a level four article, as the influence of others

by inspiration, encouragement, and direction to willingly follow in pursuit of objectives

(Darragh, 2016). Charge nurses need to be prepared and professionally developed to ensure that

staff perform optimally and are engaged in the mission of the organization. According to a level

four evidence article, sixty-five charge nurses were evaluated on their response to leadership

classes through transformative learning and after the study, staff were more engaged in unit

functioning, activities increased, greater confidence was observed in decision making, and more

assertive communication was observed (Thomas, 2011). Organizations should invest time and
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energy in developing these front-line leaders on the units to grow their staff and keep the leaders

engaging and continuing to build their team on each unit. Swearingen states in a level five

evidence article that there are three critical points regarding nursing leadership development and

includes: Nursing does not consistently develop nursing leaders, and many nursing leaders fail

due to lack of leadership knowledge, nursing leadership has a direct impact on retention and

recruitment of the nursing workforce, and individual healthcare organizations can institute a

nursing leadership program that will develop their nursing leadership talent (Swearingen, 2009,

p.112). These studies have several items in common: There is an immediate need for a Charge

Nurse Leadership Development Program, nursing leadership has a direct impact on the retention

of staff, and it is essential for charge nurses to help create a healthy work environment where

staff nurses can thrive and develop. In conclusion, there is evidence that a Charge Nurse

Leadership Development Program is vital to the success of an organization in which healthy

work environments can be built, nurses will be retained, and opportunities will flourish.

Evidence-Based Practice: Verification of Chosen Options

While reviewing the literature, significant information was obtained to include in the

Charge Nurse Leadership Development Program’s presentation. Research was performed on the

actual charge nurse leadership session and the importance that the session can offer the charge

nurses. The information obtained on retaining nurses and the actions that must be performed

were included in the Powerpoint presentation to bring awareness to the charge nurses. Mentoring

was also included in the Charge Nurse Leadership Development Program after research was

performed and noted benefits to the mentee, mentor and the organization. The inclusion of the

evidenced-based practice research into the Charge Nurse Leadership Development Program will

attempt to ensure an overall reduction in nursing turnover.

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Theoretical Framework/Evidence-Based Practice Model

Employee Motivation Theoretical Framework

Employee motivation has a direct correlation with nurse retention. According to the

theoretical framework of employee motivation in the insurance sector, six factors impact

employee motivation to include: Working environment, empowerment, rewards/incentives and

recognition, teamwork and cooperation, and job security (Mir, 2017, p.19). Each of these will be

discussed in detail to demonstrate how they also impact nurse retention and the impact that the

Charge Nurse Leadership Development Program will have on these factors. See Appendix A for

a detailed view of the Employee Motivation model.

Working Environment

The Nursing Organizational Alliance recommended nine principles of a healthy work

environment to include: Collaborative practice culture, communication-rich culture, a culture of

accountability, the presence of adequate numbers of qualified nurses, the presence of expert,

visible leadership, shared decision-making at all levels, the encouragement of professional

practice and continued growth/development, recognition of the value of nursing's contribution

and recognition by nurses of their meaningful contribution to practice (Ritter, 2011, p.29). Each

of these nine items helps to retain nurses, and these items will be discussed in the Charge Nurse

Leadership Development Program. A common reason given by staff as the basis for leaving their

current job was management or leadership (Ritter, 2011, p.30). A healthy work environment has

a direct correlation with retention of nurses in the hospital setting. In addition to a healthy work

environment, the relationship between the charge nurses and the Registered Nurses is critical to

ensure the success of a unit.

Rewards/Incentives and Recognition

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Charge nurses need the ability to reward and recognize employees that excel in their

roles. According to Gallup's analysis, only one in three workers in the United States strongly

agree that they received recognition or praise for doing good work in the past seven days, and it

is not uncommon for employees to feel that their best efforts are routinely ignored (Mann, 2016,

para.3). Employees who do not feel adequately recognized are twice as likely to say they will

quit in the next year (Mann, 2016, para.3). Charge nurses must ensure memorable recognition is

occurring on the unit to include: Public recognition via awards, certificates, or commendation,

private recognition, obtaining a high level of achievements through evaluations, promotion or

increase in the scope of work or responsibility to share trust, and personal satisfaction (Mann,

2016, para.10). Recognition should occur once every seven days to ensure that the employee

knows the significance of the recent achievements and to reinforce company values (Mann,

2016, para.11). Seventy-five percent of employees feel an award or verbal thank you increased

confidence in their skills, which ultimately fueled motivation, engagement, and overall

performance (Pollock, 2018, para.2). There is significant value in recognizing employees in

regard to retaining staff and fueling engagement.

Empowerment

Empowerment is described as the perception of being involved and supported, having

access to opportunities, resources, and power within an organization (Twigg, 2013, p.87).

Employee contributions should be encouraged and taken into consideration. Empowered work

environments are characterized by a shared governance structure that facilitates the flow of

information between Registered Nurses at the bedside and those in leadership. Charge nurses

should encourage staff participation in hospital committee meetings for increased employee

contributions to allow Registered Nurses the ability to contribute to organizational change

processes (Twigg, 2013, p.87). The ability for staff nurses to voice their concerns or suggestions
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 17

in committee meetings will help them understand the purpose and rationale behind policies and

procedures to enable their commitment and involvement within an organization (Twigg, 2013,

p.87). Charge nurses should encourage and ensure that their work empowers staff to get involved

in making positive changes for an organization.

Teamwork and Cooperation

According to 3,675 nursing staff members employed at five different hospitals and

representing eighty different patient care units, higher levels of teamwork and perceptions of

higher levels of staffing adequacy leads to higher job satisfaction with their current position

(Kalisch, 2010, p.77). There are several essential elements and interventions to improve

teamwork, to include: Promotion of staff feedback, identification of shared values, vision, and

goals, enhanced communication, coaching and implementation of guiding teams (Kalisch, 2010,

p.79). Staff should be included in discussions and decision making to build trust before

implementing changes which affect their workflow (Nurse Journal, 2018, para.17). A negative

work environment has been linked to higher turnover rates and lower patient satisfaction scores,

which will result in lower reimbursement for the hospital (Nurse Journal, 2018, para.2). One

must consider ways to improve teamwork through educational opportunities discussing

communication, conflict resolution, and leadership development for charge nurses. According to

thirty-two Registered Nurses which had an impact on fifty-five staff members on a forty-one bed

medical-surgical unit, significant positive outcomes were accomplished through teamwork and

engagement enhancement interventions (Kalisch, 2007, p.79). As a result of these interventions:

The patient falls rates decreased significantly, patient satisfaction scores increased, staff ratings

of the level of teamwork improved, and there was a significant drop in staff turnover and

vacancy rates (Kalisch, 2007, p.81). Teamwork is essential to keeping employees motivated,
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 18

engaged and it must be included in the Charge Nurse Leadership Development Program to retain

staff.

Job Security

Employees who do not fear for their jobs are more likely to perform at higher levels and

feel more significant to an employer (Heibutzki, 2018, para.3). According to the 2010 Employee

Job Satisfaction Survey Report, employees ranked job security and benefits as the two significant

contributors to job satisfaction over other factors such as career development, flexibility, and

compensation (Hastings, 2010, para.1). Employees must feel as if they meet the job requirements

and expectations that their job will be safe. Charge nurses must encourage staff to strive to reach

their potential, so they will feel more secure in their role without fear of losing their job. By

setting a motivational tone for the organization, employees are empowered with a sense of well-

being, so one will not need to question their job security (Cooper, 2010, para.1).

Mentoring Model Framework

Mentoring has a critical role in retaining nurses and The Royal Children’s Hospital in

Melbourne has developed an excellent guide and a mentoring model that will help guide this

project. There are numerous benefits of a formal mentoring model with new nurses. The mentee,

newly hired nurse, benefits by: Gaining improved knowledge and skills, abilities and attributes,

improved understanding of roles in the organization, insights into the culture and the unwritten

rules of the organization, having a supportive environment in which successes and failures can be

evaluated in a nonconfrontational manner, recognition, satisfaction and empowerment (The

Royal Children’s Hospital Melbourne, 2015). The mentor, experienced nurse or employee,

benefits by: Enhanced knowledge base, renewed enthusiasm, higher level recognition of their

worth, challenging discussions with people who have fresh perspectives, personal satisfaction,

and improved inter-personal skills (The Royal Children’s Hospital Melbourne, 2015). With the
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 19

implementation of a formal mentoring model, the organization benefits by: Improved delivery of

services through more informed and competent staff, successful mentees often become mentors,

transmitting of cultural values and norms that can contribute to a change in workplace culture,

and reduced recruitment and selection costs as a result of higher employee retention (The Royal

Children’s Hospital Melbourne, 2015). There are numerous mentoring models to be utilized to

meet the goals of an organization, however, there are not many that are simple and focus on the

support as well as the challenges that will be accompanied as a new nurse starts their journey

within an organization. The key principle involved with a formal mentoring program is that the

mentee, newer nurse, will receive support and challenge from the mentor in equal measures (The

Royal Children’s Hospital Melbourne, 2015). When a mentee receives high support/low

challenge, there is a risk of complacency whereas when there is low support and low challenge,

the mentee may become bored and disengaged (The Royal Children’s Hospital Melbourne,

2015). The ideal situation is when an employee receives high support and high challenge because

that is when an individual grows and develops (The Royal Children’s Hospital Melbourne,

2015). Mentoring has tremendous benefits and must be utilized to have an impact on reducing

recruitment expenses and turnover. See Appendix B for a detailed view of the mentoring model.

Objectives and Outcomes

The overall goal of the Charge Nurse Leadership Development Program is to attempt to

reduce the nursing turnover percentage by 10% with a specific interest in the new nurses at the

facility. The nursing turnover percentage for the entire facility in December 2018 was 20.3%.

The goal of this study is to reduce the facility Registered Nurse turnover percentage by 10%, to

equal a turnover percentage of 18% or less, equivalent to the national average nursing turnover

percentage. Table 1 and Table 2 will help to track nurse retention statistics during this project. In
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 20

an effort to reduce nursing turnover, a sixty-minute educational workshop was led by the creator

of the Charge Nurse Leadership Development Program. The workshop was conducted at an

agreed upon time available for the charge nurses during December 2018. The overall expected

outcome of this project was to empower the charge nurses on two specific units to mentor new

nurses to reduce the turnover percentages. During the workshop, statistics regarding turnover and

retention were discussed as well as how the charge nurses can contribute to creating healthy

work environments. The goal was to see a 10% reduction in the facility overall Registered Nurse

turnover as a result of the impact of the Charge Nurse Leadership Development Program

focusing on these two specific units with high Registered Nurse turnover percentage during a

three-month time frame.

Project Design

Charge nurse development will prove to be a crucial area that will help an organization

improve retention and overall positively impact quality and patient care. This study consists of a

focused educational program designed to result in a process improvement as charge nurses

become aware of their ability to influence the unit through mentoring and creating healthy work

environments on their specific units with an overall effort to benefit the organization by the

retention of Registered Nurses. A sixty-minute session was focused on numerous topics that

charge nurses have expressed a need for professional development and that have been proven to

retain nursing staff. This program will provide charge nurses with skills and knowledge

including: Effective communication, collaboration, decision making, problem solving, unit

vision, policies and procedures, risk management, conflict management, supervision, delegation,

managing behaviors of others, creating a healthy work environment, and mentoring new staff

members. This project will focus on quantitative data such as total number of Registered Nurses
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 21

on the unit, total number of resignations, and nursing turnover percentage as one looks at nurse

retention in detail. Before, during, and after the program, Registered Nurse retention data will be

collected and analyzed to see the overall effects that the focused education and efforts that the

charge nurses exhibited.

Project Site and Population

This study involves two units that have a combined maximum capacity of fifty-seven

beds within a 275-bed facility located in the southeastern United States. The focus group consists

of eleven charge nurses that are currently working on a Medical-Surgical/Oncology unit and a

General Medical-Surgical unit. Typically, these units are well-staffed with the dayshift

Registered Nurses having five patients per nurse and the nightshift Registered Nurses having six

patients per nurse on average. Forty-seven staff members currently work on these specific units

including the eleven charge nurses combined and the results from this project will be

instrumental in creating a change on the unit to positively impact the working environment and

overall staff satisfaction. The eleven charge nurses are very experienced, and the results of this

study will be dependent if they allow their experience to impact their willingness to learn the key

objectives in the Charge Nurse Leadership Development Program.

Setting facilitators and barriers. Information regarding planned turnover that was

known before the leadership development series was conducted will be important to mention so

that a note can be made regarding that specific turnover. For instance, if there were nurses that

graduated with advanced degrees and moved on in their career, a reflection was noted in the data.

If there were significant changes that took place such as increased staffing ratios, pay reductions,

or any other changes that affected the retention and attrition of the staff, this was noted. Nursing

Administration was made aware of the project and was instructed to keep the staffing ratios
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 22

consistent by utilizing float pool staff if needed through the three months of the study, if possible.

Great efforts were spent on ensuring that during these three months, there were not extremes that

would positively or negatively affect the program.

Implementation Plan/Procedures

The project was conducted on each subject that was elaborated on during the Charge

Nurse Leadership Development Program. The following topics were discussed in detail:

Effective communication, collaboration, decision making, problem solving, creating a unit

vision, performing research development activities, the importance of being more knowledgeable

regarding policies and risk management, team building exercises, conflict management,

supervision and delegation, managing behaviors of others, creating a healthy work environment

on the unit, and mentoring new staff members. One sixty-minute educational workshop was led,

and these topics were discussed thoroughly with the utilization of a PowerPoint presentation to

ensure that all items were covered. There was an opportunity for questions to be answered at the

end of the presentation to ensure that learning occurred. The presenter made certain that the

presentation was interactive and informative. During the twelve weeks after the conclusion of the

Charge Nurse Leadership Development Program, data was gathered to assess the change in

turnover percentages. See Appendix C for a detailed view of the PowerPoint presentation that

was utilized.

Measurement Instruments and Data Collection Procedures

The following instruments were used to measure the outcomes of this study for each unit:

The total number of nurses, the total number of nurse resignations, and nursing turnover

percentage. Collection of data from the previous six months from Human Resources and every

month during the leadership series occurred to measure the effectiveness of the program. With
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 23

the information that was collected from Human Resources regarding turnover, the effectiveness

of the charge nurse leadership program was measured and evaluated.

Data Analysis

This project supplied multiple data sets to measure the effectiveness of the Charge Nurse

Leadership Development Program. First, it was imperative to collect information from Human

Resources to quantitatively analyze the following items compared month-to-month: Total

number of nurses, the total number of nurse resignations and nursing turnover percentage.

The overall nursing turnover percentage for the Medical Surgical unit from May 2018 till

March 2019 was an average of 2.37% (SD = 2.99, SEM = 0.90, Min = 0.00, Max = 8.69,

Skewness = 0.80, Kurtosis = -0.47). ). Regarding skewness, the variable is symmetrical to its

mean. With a kurtosis less than or equal to 3, a normal distribution was noted and there was

reduced tendency for outliers to be produced. The Medical-Surgical unit saw an increase in

terminations from December 2018 through March 2019 with one termination per month. One

may also look at the previous trend over the summer months and notice that even though they

had one resignation per month, two resignations per month was never reached after the Charge

Nurse Leadership Development Program. The Medical-Surgical unit had a spike in the turnover

percentage in August 2018 with a maximum of 8.69%. From May 2018 through November 2018,

the mean turnover percentage was 1.812%, whereas after the program was presented in

December 2018 through March 2019, the mean turnover percentage rose to 3.355%.

However, the overall nursing turnover percentage for the Oncology Medical-Surgical unit

from May 2018 till March 2019 was significantly lower with an average of 1.63% (SD = 2.27,

SEM = 0.68, Min = 0.00, Max = 4.76, Skewness = 0.57, Kurtosis = -1.66). As with the Medical-

Surgical unit, the variable was symmetrical to its mean regarding skewness. Also, with a kurtosis
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 24

less than or equal to 3, a normal distribution was noted and there was a reduced tendency to

produce outliers. The Oncology Medical-Surgical unit’s nursing turnover percentage spiked at

4.76% in July 2018. From May 2018 through November 2018, the mean turnover percentage

was 2.568%, whereas after the program was presented in December 2018 through March 2019,

the mean turnover percentage was reduced to 0%. The Oncology Medical-Surgical unit had zero

terminations from December 2018 through March 2019.

The observations for the Medical Surgical Unit Registered Nurse headcount had an

average of 23.27 Registered Nurses (SD = 1.01, SEM = 0.30, Min = 22.00, Max = 25.00,

Skewness = 0.66, Kurtosis = -0.52). When evaluating each month in detail, it was noticed that

when the unit had less Registered Nurses, for example December 2018 through March 2019, a

higher turnover percentage with one turnover per month was noted.

The Oncology Medical-Surgical unit’s Registered Nurse headcount had an average of

21.91 Registered Nurses (SD = 1.04, SEM = 0.31, Min = 20.00, Max = 23.00, Skewness = -0.37,

Kurtosis = -1.06). The number of Registered Nurses were more consistent than the Medical-

Surgical unit from December 2018 through March 2019 and had remarkable lower turnover

percentages for those months.

Cost-Benefit Analysis/Budget

Completing this project will involve cost, particularly in the area of ensuring that the

charge nurses are compensated by a large metropolitan hospital in the southeastern United States

for receiving the education. Eleven charge nurses attended the workshop lasting one hour. Eleven

hours of nursing education totaled an estimated $275.00. That figure is obtained by taking the

average cost of charge nurses' hourly pay ($25) for eleven hours to be educated. No other

expenses were incurred with the initiation of this project. With the average cost involved in the
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 25

turnover of one bedside nurse costing $49,500 and this organization having spent $1,061,214 in

2018 due to turnover, the investment in this charge nurse development program is a logical

conclusion (Nursing Solutions, 2018, pg. 1). See Appendix I.

Timeline

Following a strict timetable ensured that the project was completed promptly and that

outcomes were measured. A meeting was held with the Chief Nursing Officer at a hospital in the

southeastern United States to discuss the project proposal. Literature was reviewed and goals

were established for this project. Then, the plan was submitted for Institutional Review Board

(IRB) approval. Once approved, information from the literature research was gathered to create a

PowerPoint presentation in November 2018. One presentation lasting sixty minutes was

scheduled in early December 2018. The presentation was held at the large metropolitan hospital

in the southeastern United States to ensure adequate attendance. Surveys were given to all the

charge nurses in attendance to gather data. Monthly sessions were held with the Medical-

Surgical Director to discuss barriers that are involved with the outcomes of this project. Starting

in March 2019, data was collected and analyzed to determine the effectiveness of the Charge

Nurse Leadership Development Program and its impact on regarding retention of Registered

Nurses. In April 2019, the manuscript was finalized, and a poster and presentation developed to

present the project. In June 2019, the project was presented to Jacksonville State University

faculty. Following this timeline ensured that the project's outcome was evaluated on time. See

Appendix H for a detailed outline that was utilized.

Ethical Considerations/Protection of Human Subjects

The Jacksonville State University Institutional Review Board (IRB) approval was

obtained before initiating the study. Procuring IRB approval ensured the safety of human
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 26

subjects and that their rights were not violated (Center for Innovation in Research and Teaching,

n.d., para 3). Ethical standards prevent against the fabrication or falsifying of data and therefore,

promote the pursuit of knowledge and truth which is the primary goal of research (Center for

Innovation in Research and Teaching, n.d., para 1). No associated risks were involved in this

study, but efforts focused on securing that rights were not violated during this study.

An ethical climate represents these shared perceptions of organizational practices related

to ethical decision-making and reflection and includes issues of power, trust, and human

interaction within an organization (Ulrich, 2007). Improving the ethical climate may be essential

for addressing ethics, stress, job satisfaction, and turnover intentions (Ulrich, 2007). Studies have

proven that Registered Nurses feel powerless and overwhelmed with ethical issues in the

workplace and frustration and fatigue develop when they cannot resolve ethical issues (Ulrich,

2007). One study found that 80% of oncology nurses had a stress scale of six on a ten-point scale

and identified thirty-two different types of ethical dilemmas that they encountered within the past

year (Ulrich, 2007). Many healthcare providers experience moral distress in their workplace and

some of these healthcare providers leave their positions and in some cases, leave the profession

altogether in response to unresolved moral distress and many that stay, report high levels of

stress, disengagement, and emotional withdrawal (Hospital News, 2019). If one is to make any

impact nursing turnover, the ability of Registered Nurses to resolve ethical issues to reduce their

stress must be a focus.

Conclusion

This project resulted in some outstanding results in the first three months of data collection after

the implementation of the Charge Nurse Leadership Development Program. The Medical-

Surgical unit consistently for three months in a row managed only one Registered Nurse
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 27

termination per month. After the Charge Nurse Leadership Development Program

implementation, there was not a month where the result was greater than one resignation per

month, such as in August 2018 where there were two resignations in one month. Unfortunately,

consistent staffing levels were not able to be maintained on this unit due to high census through

late 2018 and early 2019, which could have led to the resignations. On a regular basis, the staff

had seven and eight patients per nurse during the data collection period, which the standard nurse

patient ratio prior to the implementation of the project was five to six patients per nurse. The

Oncology Medical-Surgical unit had great results from the Charge Nurse Leadership

Development Program and has sustained zero resignations from December 2018 through March

2019. Consistency with staffing ratios and excellent buy-in from the charge nurses on the

Oncology Medical-Surgical unit has ensured success with the program. However, this study

would benefit from the collection of data for an additional three to six months to gain additional

clarity on the effectiveness of the project.

THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 28

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THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 32

Appendix A

Employee Motivation Model

(Mir, 2017, pg. 22)

THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 33

Appendix B

Mentoring Model
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 34

Appendix C

Presentation Presented During the Charge Nurse Leadership Development Program

THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 35
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 36
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 37
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 38
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 39
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 40
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 41
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 42
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 43
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THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 45
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 46

Appendix D

Registered Nurse Terminations

2.5

1.5

0.5

Medical-Surgical Unit Oncology Medical-Surgical Unit

THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 47

Appendix E

Registered Nurse Headcount

30

25

20

15

10

0
May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

Medical-Surgical Unit Oncology Medical-Surgical Unit

THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 48

Appendix F

Nursing Turnover Percentage

10
9
8
7
6
5
4
3
2
1
0
May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

Medical-Surgical Unit Oncology Medical-Surgical Unit

THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 49

Appendix G

Overall Hospital Turnover Percentage

23

22

21

20

19

18

17

16

15
May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

Turnover Percentage Goal

THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 50

Appendix H
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 51

Appendix I

Total Spent on Nursing Turnover Orientation in 2018 - $1,061,214.00

Average Cost of 1 Bedside Nurse Turnover - $49,500.00
The Cost for 11 Charge Nurses to Attend a 1 Hour Workshop - $275.00
THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 52

Table 1

Medical-Surgical Unit

Month/Year RN Headcount Total Number of Nursing Turnover

Resignations Percentage

May 2018 24 0 0%

June 2018 25 0 0%

July 2018 25 1 4%

August 2018 23 2 8.69%

September 2018 23 0 0%

October 2018 23 0 0%

November 2018 23 0 0%

December 2018 23 0 0%

January 2019 22 1 4.54%

February 2019 23 1 4.34%

March 2019 22 1 4.54%

THE EFFECTIVENESS OF A CHARGE NURSE LEADERSHIP 53

Table 2

Oncology Medical-Surgical Unit

Month/Year RN Headcount Total Number of Nursing Turnover

Resignations Percentage

May 2018 22 1 4.54%

June 2018 23 1 4.34%

July 2018 21 1 4.76%

August 2018 21 0 0%

September 2018 21 0 0%

October 2018 23 0 0%

November 2018 23 1 4.34%

December 2018 23 0 0%

January 2019 20 0 0%

February 2019 22 0 0%

March 2019 22 0 0%