Leaders of a rural Southwest Oklahoma hospital requested the development of an evidence-based program that could transform unit charge nurses into effective leaders in order to improve the leadership of direct care nurses. Nursing executive leadership discovered staff members were demonstrating high levels of stress, dissatisfaction, and burnout. Press-Ganey survey results revealed that staff felt they were not supported and did not believe nurses cared for patients' or other co-workers' well-being or safety. The Hospital Consumer Assessment of Healthcare Providers and Systems outcome scores, which were below hospital and national desired benchmarks, revealed that patients were not satisfied with the care they received. Thus, the goal of this project was to use evidence to craft a program and evaluation plan that could be used by the hospital to develop stronger charge nurse leaders. A detailed examination of evidence supported the development of a program based on the relationship-based care (RBC) model. The RBC model is a transformational leadership development program that increases leadership skills and positive interaction between people. A full program was adapted from the RBC model and designed for the rural hospital. An evaluation plan to measure the short-and long-term objectives was developed. Implementation is expected to create social change by imparting charge nurses with leadership and relationship skills, thus empowering them with greater abilities to provide care. Benner's novice to expert and Watson's theory of caring models served as the foundation of the RBC model. The goal is to present the results at the hospital level and to disseminate the findings locally at professional nursing leadership conferences.

Staff nurses are frequently placed in charge nurse positions without the necessary formal training. The long-term goal of this project was to develop a curriculum for a formal institutional leadership workshop for the charge nurses at the practicum site. The Johns Hopkins Nursing Evidence-Based Practice model and Lewin's change theory were used to guide the development and implementation of the workshop. Data were collected using a focus group approach with 4 novice and 5 expert medical-surgical charge nurses. The short-term goal of the project was to understand the charge nurses' perceptions of leadership and the challenges as a front-line leader. Participating nurses were recruited from staff meetings and from a hospital flyer. Each participant answered the 3 leadership questions. The charge nurses' statements were categorized and color-coded to identify emerging themes from repetitions of words and patterns; themes were subsequently prioritized from the most to the least occurring. Member checking with participants as well as preceptor verification and validation of 10 themes that were utilized to develop the curriculum: communication, patient safety, roles, teamwork, conflict management, generational diversity, mentoring, cheerleader, prioritization, and delegation. Implementing the workshop 4 hours per month over a 3-month period and formal mentoring was recommended for optimal sustainability based on the proposed theoretical framework. Implications for positive social change include the potential for enhancing the quality of patient care delivered and improving patient safety as a result of charge nurse leadership being modeled.

This thesis focuses on the work of charge nurses in intensive care units (ICUs) as first-line managers. The practical part of the thesis aims at assessing the experience with nursing management in day-to-day routine, especially with the management of change introduction, conflict resolution and motivation of employees. It further compares different charge nurses' career beginnings. The second part of the research deals with personal typology of charge nurses. Twenty six ICU charge nurses were included into the study. The results indicate that charge nurses are not being specifically prepared for their job and that they particularly lack any special education in management. They usually solve conflicts either by compromise or via a directive. Most charge nurses intend to introduce changes into daily practice and they perceive changes as positive. Conversely, they describe the attitude of their subordinates towards changes as negative. Charge nurses generally know the motivators of their employees; however, they excessively and inappropriately use praising as motivation tool. Although not standardized and not used generally, a formal evaluation of employees is considered by charge nurses as a possible way to improve motivation. Allover, the study shows the need for a more thorough management training...

Syftet med denna studie var att beskriva ledningssjuksköterskan upplevelser av ledningsarbetet vid svårhanterbara situationer på en akutmottagning. Flertal studier visar att det är viktigt med erfarna och kompetenta ledningssjuksköterskor för att en akutmottagning ska fungera optimalt. Ledningssjuksköterskans ansvarsområde innefattar bland annat att vara akutmottagningens kontaktperson, ha ledningsansvar i händelse av katastrof och stödja medarbetare i att strukturera och organisera arbetet på olika positioner. För att bibehålla och säkerställa god och säker vård är det till stor vikt för sjuksköterskor att de har stabil ledning med ledningssjuksköterskan som ger stöd, verkar för gott samarbete och besitter hög kompetens. Detta i strävan för att finna ny kunskap som kan leda till förbättrat ledningsarbete och därmed ökad patientsäkerhet. Den metod som användes var kvalitativa intervjuer med åtta ledningssjuksköterskor från fyra olika akutmottagningar i Storstockholm området. Intervjuerna har transkriberats och analyserats för att lyfta fram ledningssjuksköterskornas erfarenheter som är relevanta till syftet. I denna studie har ledningssjuksköterskornas erfarenheter sammanfattats i tre kategorier och därmed kartlagt deras erfarenheter i olika aspekter. Analysen gav tre kategorier; upplevda orsaker till svårhanterbara situationer, upplevda känslor och intryck vid svårhanterbara situationer och upplevelse om hantering vid svårhanterbara situationer. De tre kategorierna åskådliggör principer från ledningsarbetet som är känt sedan tidigare forskning men också en hel del ny anmärkningsvärd information. Genom denna studie har det fångats upp att ledningsarbetet påverkas negativt av att ledningssjuksköterskor har arbetsuppgifter som försvårar helhetsperspektivet och därmed orsakar svårhanterbara situationer på akutmottagningen. En annan betydande iakttagelse som avslöjats var att ledningssjuksköterskor anser att sökandet och användandet av riktlinjer försvårar handläggningsarbetet på akutmottagningen. Vidare har denna studies intervjuer belyst konsekvenser av hög arbetsbelastning i samband med brist på resurser som resulterar i att personalens och anhörigas välmående försummas. En ytterligare anmärkningsvärd observation är att en av de inkluderade akutmottagningarna fortfarande är uppbundna med nära patientarbete samtidigt som de har ledningsansvar på akutmottagningen. Detta trots redovisad beprövad erfarenhet att ledningssjuksköterskor behöver vara frikopplade för att kunna hantera svårhanterbara situationer till deras bästa förmåga. Slutligen har denna studies underökningar bevisat att ledningssjuksköterskor upplever att de med erfarenhet upptäcker nya viktiga egenskaper som krävs som ledare vid hanteringen av svårhanterbara situationer. Slutsatsen av denna studie är att det finns möjlighet att minimera svårhanterbara situationer och dessutom effektivisera ledningsarbetet. / The aim of this study was to outline the experiences of charge nurses in their leadership role when dealing with challenging situations in the emergency department. This was done with a view to gain new insights/understanding that would improve leadership (skills) and hence the quality and safety of patient care. Several studies have shown that it is important to have experienced and competent charge nurses for an emergency department to perform/function to its optimal capacity. The responsibilities of the charge nurse are many and include; being the first point of contact for the emergency department, taking charge if a major incident occurs, and to support the staff by co-ordinating and managing the workload between all the different areas in the department. Financial cutbacks to the Swedish health care system have led to reorganisation and increased demand on the emergency departments. To continue to deliver good quality and safe care it has therefore become even more important for frontline health care staff to have/receive clear and stable leadership from a highly competent charge nurse who supports and reinforces teamwork. This was done with a view to gain new insights/understanding that would improve leadership skills and hence the quality and safety of patient care. The method used in this study was semi-structured qualitative interviews with eight charge nurses from four different emergency departments located in Stockholm. The interviews have been processed through a qualitative manifest content analysis to highlight the charge nurses’ experiences in relation to the aim of the study. The charge nurses´ experiences have been summarised into three categories to capture the different perspectives; i) perceived reasons for challenging situations, ii) feelings and impressions associated with challenging situations, and iii) coping abilities in challenging situations. The three categories revealed similar findings to earlier research studies into leadership skills but also unravelled a lot of new notable information. This study shows that effective leadership is prevented when the charge nurse has got multiple responsibilities that distract from gaining an overall overview of the department. This in turn creates challenging situations in the emergency department. Another important observation was that the charge nurses’ found that the localisation and usage of guidelines further complicated rather than improved the work in the emergency department. Furthermore, the interviews highlighted the consequences of the financial cutbacks within the health care sector that have had negative implications on the wellbeing of staff and patient relatives. A pertinent finding was that one of the emergency departments in this study still expects the charge nurse to be responsible for hands on patient care whilst maintaining an overview of the workflow in the emergency department. This despite the proven importance of the charge nurse to give her undivided attention to provide effective leadership. Finally, this study has shown that charge nurses found that with experience they discovered new abilities that are required to provide effective leadership in challenging situations. In conclusion this study showed that there are opportunities to minimise challenging situations from arising but also to improve the efficiency of the leadership work.

Bakgrund: För att följderna av en allvarlig händelse i samhället ska minimeras åligger det varje region att ta fram en katastrofmedicinsk beredskapsplan och planera sjukvården så att katastrofmedicinsk beredskap upprätthålls. Vid en allvarlig händelse aktiveras en lokal katastrofmedicinska beredskapsplanen för respektive sjukhus. Ledningsansvarig sjuksköterskapå akutmottagningen är ofta den som tar emot larmet om en allvarlig händelse och aktiverar katastrofplanen.  Syfte: Granska och jämföra svenska regioners katastrofplaner för att belysa vilken roll den ledningsansvariga sjuksköterskan på akutmottagningen kommer få vid en allvarlig händelse. Metod: Deskriptiv tvärsnittsstudie med kvantitativ ansats. Insamling av enkät och styrdokument från den största akutmottagningen i varje region.  Resultat: Majoriteten av akutmottagningarna (60%) hade inga formella krav på tidigareerfarenhet och utbildning för ledningsansvarig sjuksköterska. Utbildning och övning i ledarskap och katastrofberedskap för den ledningsansvariga sjuksköterskan gavs, men i en begränsad omfattning. Vid en allvarlig händelse delges den ledningsansvariga sjuksköterskanmånga betydelsefulla arbetsuppgifter och ansvarsområden utifrån akutmottagningarnas lokalakatastrofplaner. Endast 10% av de regionala katastrofplanerna ger en utförlig beskrivning av den ledningsansvariga sjuksköterskans funktion.  Slutsats: Ledningsansvarig sjuksköterska utgör en central funktion vid en allvarlig händelse. Det bör ställas höga krav på kompetens och funktionen behöver lyftas fram i regionernas katastrofplaner, vilket i nuläget brister i många regioner. Ledningsansvarig sjuksköterska utan tillräcklig utbildning och erfarenhet riskerar att bli en svag länk i systemet kring hela hanteringen av en katastrofhändelse. Något som kan ge konsekvenser i form av en icke fungerande akutmottagning vilket i sin tur kan påverka resten av vårdkedjan och utgöra en belastning på andra samhällsbärande funktioner. / Background: To minimize the consequences of a major accident or disaster, every region has to develop an Emergency Operations Plan and ensure the health care system is able to provide high-quality care during all circumstances. In case of a major accident or disaster, a local emergency response plan is activated at each hospital. The charge nurse is usually the person who receives the alarm call and activates the local emergency plan in the event of a disaster.  Aim: To review and compare Emergency Operation Plans in Swedish regions to highlight the role of the charge nurse in the event of a disaster.  Study design: The study was performed as a quantitative cross sectional study, using questionnaires and a collection of regulatory documents as a data collection method, and descriptive statistics for analyzing the data.  Results: A majority (60%) of the emergency departments did not express any formal requirements in the form of higher education or previous experience for a charge nurse. Education and exercise in leadership and disaster management was provided, but to a limited extent. In the event of a disaster, many important tasks and areas of responsibility are assigned to the charge nurse, according to the local emergency plans. Only 10% of the regional Emergency Operation Plans provide a detailed explanation of the charge nurse function. Conclusion: The charge nurse plays a pivotal role at the emergency department in the event of a disaster. The requirements for the position should be high and the position needs to be highlighted in the regional Emergency Operation Plans. A charge nurse lacking enough education and experience may become a weak link in the chain of disaster management. This may result in ramifications in form of a dysfunctional emergency department affecting otherparts of the hospital and society.

Bakgrund: Arbetsmiljön i akutsjukvården, som många gånger är krävande och hektisk, kan vara påfrestande för ledningssjuksköterskan då de innehar en nyckelposition för hela sjukhuset. När det råder crowding på akutmottagningen och resurserna inte räcker till för att möta patienters vårdbehov är det är direkt livsavgörande att personalen som omhändertar kritiskt sjuka patienter besitter hög kompetens och känner sig trygga i sitt arbete. För att säkerställa och bibehålla en patientsäker vård är det av stor vikt för personalen att de har en ledningssjuksköterska som verkar för gott samarbete, ger stöd och handledning. Syfte: Att undersöka ledningssjuksköterskans erfarenheter och hantering av crowding på akutmottagningar. Metod: Studien utfördes på två akutmottagningar i Sverige och kvalitativ metod innehållande enskilda intervjuer valdes då ambitionen var att undersöka ledningssjuksköterskors erfarenheter och hantering av crowding på akutmottagning. Kvalitativ innehållsanalys användes vid analys av textmaterialet. Resultat: Studiens fynd omfattade fyra kategorier och dessa var; Patientosäkerhet vid crowding, Strukturella förutsättningar, Upplevelsen av crowding och Att leda vid crowding. Diskussion: Ledningssjuksköterskor på akutmottagningen blir ofta utsatta för hög arbetsbörda och tidspress då det råder crowding. Kollegors kompetens och stöd från arbetsgruppen är av stor vikt för att klara av att upprätthålla patientsäkerheten. Ett förbättrat stöd från ledningen, erfarenhet och adekvat utbildning ger ledningssjuksköterskan bättre förutsättningar för att hantera crowding. / Background: The working environment within the emergency department, which in many cases are demanding and hectic; can be strenuous for the charge nurses as they hold a key position in the hospital. When there is crowding in the emergency department and the resources are not sufficient to meet the patients' care needs it is directly vital that the personnel who take care of critically ill patients must possess high qualifications and feel secure in their work. To ensure and maintain patient safe care it is of utmost importance for the personnel to have a charge nurse who initiates good collaboration, gives support and guidance. Aim: To investigate the charge nurse experiences and management of crowding at the emergency department. Method: The study was performed at two emergency departments in Sweden. A qualitative method consisting of separate interviews was used as the ambition was to investigate the charge nurses' experience and management of crowding at the emergency department. A qualitative analysis of content was used for the analysis of the body of the interviews. Results: The findings of the study comprise four categories: patient insecurity during crowding, structural prerequisites, experiences of crowding and to lead during crowding. Conclusion: The charge nurses at the emergency department are often exposed to extensive workload and time pressure due to crowding. The colleagues' competence and support from the team are of utmost importance to maintain the safety of the patients. Improved support from the management and adequate training give the charge nurse enhanced prerequisites to deal with crowding.

Akutsjukvården i Sverige är en samhällsviktig verksamhet i vardag, kris och i händelse av krig. Den operativa ledningen på akutmottagningar sköts av en sjuksköterska med ledningsansvar, vars uppdrag är att leda och fördela arbetet under ett skift. På akutmottagningar i Sverige arbetar såväl tillsvidareanställd ordinarie personal med olika erfarenhetsnivå, liksom bemanningsanställd personal under förhållanden som kan definieras som påfrestande. Syftet med denna studie har varit att bidra med förståelse av ledarskap i akutsjukvårdens kontext genom att undersöka upplevelser av ledarskap av tillfälliga grupper under påfrestande förhållanden i rollen som ledningssjuksköterska. Med en kvalitativ ansats genomfördes sex semistrukturerade intervjuer med ledningssjuksköterskor från olika akutmottagningar i Region Stockholm. Resultatet analyserades genom en tematisk analys där en i Sverige etablerad ledarskapsmodell användes. Analysen genererade fyra teman som beskriver rollen och sammanhanget ledningssjuksköterskor verkar i, vad som kännetecknar påfrestande förhållanden i akutsjukvården och vilka omgivnings- och ledarfaktorer som påverkar ledarskapet hos ledningssjuksköterskor. Ett resultat av studien är en empirisk tillämpning av generell ledarskapsteori i akutsjukvårdens kontext. Studiens viktigaste bidrag är att ledningssjuksköterskor anpassar sitt ledarskap efter graden av påfrestning och personalgruppens kompetens, erfarenhet och behov av stöd. Resultatet indikerar också att kännedom om personalgruppens kompetens kan vara av särskilt betydelse under påfrestande förhållanden med tidsbrist, osäkerhet och psykiska påfrestningar som följd. / Emergency healthcare in Sweden holds a vital societal function in ordinary circumstances, crisis situations, and in the event of war. The operational management within emergency departments is lead by a nurse in charge, tasked with the responsibility of leading and allocating work during a shift. Within Swedish emergency departments there is a mix of permanently employed regular staff with varying levels of experience and temporary staff working under conditions that can be defined as demanding. The aim of this study has been to contribute to an understanding of leadership within the context of emergency healthcare by examining experiences of leadership of temporary groups during demanding conditions in the role of a charge nurse. A qualitative study involved conducting six semi-structured interviews with charge nurses from various emergency departments in the Stockholm Region. The results were analyzed using a thematic analysis utilizing a well-established leadership model in Sweden. This analysis generated four themes describing the role and context in which chargenurses operate, what characterizes demanding conditions in emergency healthcare, and which environmental and leadership factors affect the leadership of charge nurses. An outcome of the study involves the empirical application of general leadership theory. The primary contribution of this study is that charge nurses adapt their leadership based on levels of adversity and the competence, experience and support needs of the staff group. The results also suggest that awareness of the staff group’s competence can be particularly significant under demanding conditions, including time constraints, uncertainty and stress.