Taking Charge: Lessons in Leadership

I recently took a promotion to become full time Charge Nurse on my Med-Surg floor. While I was excited for the opportunity to take on a leadership role, I also felt a fair amount of anxiety about how I would be received. First of all I am young (and look even younger, to boot!), leading people sometimes 10+ years my senior both in age and nursing experience. Second, I am a relatively new addition to this floor, and I realized that many people could feel that I hadn't fully "paid my dues"yet. In spite of these things, I recognized that this new role would further facilitate my passion to support and educate nurses,  and I decided to jump in with both feet!

I've given a lot of thought to what it takes to be a great Charge Nurse. Some things are given: you know how to do and teach the skills your floor nurses use, etc. There are, however, many intangible aspects of leadership that have a great impact on your success. I've still got a long way to go to fill these big shoes, but I thought I would share some of the things I've learned so far.

1.) Respect is earned. I can't make anyone respect me or my role, but I can be a person who deserves respect. I subscribe to a servant leadership style. Med-Surg nursing in back-breaking, dirty work. When you are on the floor, it sometimes feels like you are in the absolute trenches of your profession. People are often quick to resent those "away from the bedside" who "don't know what its like". My favorite charge nurses are the first ones to answer the call lights, clean incontinent patients or take a patient to avoid overloading the floor. I strive to be that charge nurse. One answered call light says, "I'm in your corner" better than any number of conversations.

2.) My nurses are my first priority.  Charge nurses are responsible for the overall flow and quality of the care received on the floor. That means that I am in near constant contact with Bed Management, Social Services, and the House Supervisor to help keep things running smoothly. It also means that I'm rounding on patients and doing quality audits for management on a daily basis. For me, however, the most important part of my job is serving as a resource for my nurses. I judge the success of my day by the number of my nurses that get out on time.

3.) Know when to say "No".  Unlike being on the floor, Charge Nurse duties have a relatively flexible time frame, and, at our hospital, we don't take patients. That means that I can usually re-arrange my to-do list to help other nurses, and nurses know that I am their 'go-to'. However, there are eight nurses, and only one Charge so I can get stretched pretty thin on any given day or hour. I've had to learn when to say, "I can't now, but let me find you someone who can". If you juggle more than you can handle, you will inevitably drop one or all of your items. Better to take on a little less, be reliable and consistent, than to take on too much and drop the ball.

4.) Gripes go up. No floor is perfect, which means there will always be gripes about one thing or another. There will always be personality conflicts. It doesn't help unit morale in the slightest, however, to have a visible person complaining all the time. For better or for worse, it can and will impact the floor. I always made an effort disengage from work gossip or drama, but now it is essential to my role. I I try to take any concerns I have have to go to the appropriate person, up the chain of command, or keep them to myself. I learned this one the hard way.

5.) Be Sincere. People make mistakes, and in charge, yours will impact your coworkers. Apologize quickly and genuinely. Actively listen to people. Approach people honestly and you will be well received.

6.) Support your new nurses. Whether they are new grads or just new to your specialty, you have to give a little extra love to those with less experience. There is no "entry-level" nursing position, so the learning curve is steep and overwhelming for many people. Today's new grads are the nursing leaders of tomorrow. I would not be where I am if it were not for my 'mama-bear' nurses who took me under their wings while I was still mastering nursing skills and judgement. I believe that if nurses feel supported and heard, floors will have higher staff retention. The higher the retention, the more opportunity for quality team building and mutual support among staff members.

Decoding the Code

My first patient coded from a respiratory arrest when I was six months out of school. Code Blue. No amount of BLS training can actually prepare you for your first patient arresting before your eyes. You think to yourself, or maybe you even scream it out loud, "I need some help in here!" Then you realize, "Wait, I am the help", and your stomach drops into the floor.

New-grads experiencing their first code

I was called to the room because the patient was having an "anxiety attack." She was breathing 30-40 times a minute, I felt her pulse pounding at over 200 beats per minute. Then, no pulse. I was in disbelief, readjusting my fingers along her wrist thinking I had misplaced them. The only pulse I felt was mine, pounding through my fingertips. My coworker called the code and an onslaught of doctors, nurses, pharmacists and respiratory therapists flooded the room. Somebody shoved suction equipment into my hands, and I stared helplessly at it; any knowledge of this equipment that I previously held was no longer there, my mind was frozen.

Experience has shown me that an efficient code runs like an orchestra playing an exquisite piece. Everyone knows their part, and plays it effortlessly. This is the part that BLS doesn't teach you. A near-perfect code should go something like this:

The primary nurse calls the code, lays the bed flat, and begins chest compressions. Second, floor nurses should bring the code cart to the room, and set up oxygen to the bag-valve mask to begin bagging the patient. Usually by this time, the code team arrives. As soon as the code team arrives, the primary nurse should delegate chest compressions to someone else. This way she can communicate patient history and SBAR to the doctor running the code. Respiratory Therapy will exclusively manage the airway from this point. and a backboard will be placed under the patient in between rounds of chest compressions. Duties need to be assigned by either the MD running the code, the Supervisor or the Charge Nurse. Someone documents interventions, someone pushes medicines, and people need to form a line to relieve the person doing chest compressions. In reality, people usually assign themselves by calling out, "I'm writing!" or "I'm next to the IV!" A pharmacist and a Critical Care nurse manage the code cart.

Inevitably, there are too many people in a room during a code. Not having enough help will never be a problem in the acute care setting. People will be standing around hoping to get in on the action, reminding me of this vulgar Dane Cook sketch that was popular while I was in college. At some point you will have to ask people to step out for lack of space!

The biggest mistake many new-grads (and experienced nurses!) make is focusing on the wrong data. Many times you spend precious time frantically asking yourself, "what did I miss?" instead of asking yourself, "what do I do now?". There is a lot of anxiety surrounding codes. Many experienced nurses feel out of practice, and many new-grads feel totally unprepared. My approach is to know what you will personally do in a code before a patient ever arrests. For example, I like to document or "write" during a code. If that is already taken, I jump in line for chest compressions. If that's taken, I get out of the way.

What are your experience with codes? What advice do you have for the new RN or the out-of-practice nurse?