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Who’s In Charge?


Through her almost three decades of reviewing medical records in nursing malpractice cases, Laura Mahlmeister, RN, PhD, has seen an increasing emphasis and scrutiny on charge nurses’ response to emergency events and to problems on units that jeopardize patients’ well-being.

“The charge nurse is being increasingly drawn in to claims of negligence if they do not respond to assist the nurse at the bedside and evaluate the quality of the care,” says Mahlmeister, who is president of the San Francisco-based quality improvement and risk management company Mahlmeister and Associates and a staff nurse in the Birth Center at San Francisco General Hospital.

Mahlmeister has written and presented extensively on the issue of charge nurses, including an article about professional role development for charge nurses in the spring 2006 Journal of Perinatal & Neonatal Nursing.

“The charge nurse role is not simply a shift role where you do some extra tasks,” she says. “It’s not just a job — it’s a professional component of registered nursing care that requires supervision, surveillance, and oversight. [Charge nurses] have to have a perspective that rises above the bedside. They have to look at staffing issues, patient conditions, environmental issues that impinge on patient safety and care.”

The complexity of care in facilities today warrants a unit-based coordinator of care — the charge nurse — who has the pulse of the status of the unit, she says. By understanding the condition of all the patients on the unit, the charge nurse can rapidly alert administration for risk containment when a potential disaster arises.

“I would call it a pivotal role in any setting for reducing the risk of patient injuries,” she says. “And that reduces the risk of lawsuits for bedside nurses and the charge nurses themselves and ultimately the hospital.”

But many charge nurses do not fully understand that. “I think a lot of charge nurses don’t understand they are ultimately responsible for everything that happens in their unit,” comments Rita Kae Restrepo, RN, BS, CPAN, who works in the recovery room at San Francisco General, sometimes as a charge nurse. She is also a legal nurse consultant. “I’ve read depositions where the nurse will say, ‘I’m just a resource person. That’s all I’m there for.’ They are more than that, but they don’t understand the role.”

That role is multi-faceted, Mahlmeister says. Charge nurses need to be clinical experts who are first responders in any emergency situation. They need to be well-versed in policies and procedures and, through constant monitoring and surveillance, anticipate problems before they happen. Additionally, charge nurses need to be diplomats accustomed to addressing the concerns of patients and their families.

Recommended training

Because of the enormity of those responsibilities, Mahlmeister recommends a professionalization of the role, as has been done at SF General and other facilities for several years. Charge nurses should receive formal education about their professional and legal responsibilities in the role, including information about case law against charge nurses alleged to be negligent, as well as specific training regarding policies and procedures in their facility, she says. Charge nurses should undergo a preceptored period of training in which their skills and expertise are evaluated, as well as annual evaluations. And in recognition of the magnitude of the role, charge nurses should receive a shift differential.

Although some facilities still choose a charge nurse by randomly assigning the charge duties to someone on the shift, others limit the role to those who have received additional education and training specific to charge nursing. Ideally, charge nurses should not have their own patient assignments so they can fully perform their duties as charge nurses, Mahlmeister says.

“When charge nurses are placed in situations where they have to carry a full patient load, maintain the charge nurses’ roles and responsibilities, and then in some units they have to triage or admit all new patients coming in, it becomes an impossible task,” she says. “It’s a prediction for failure.”

Take action

Karen Boyle, RN, BSN, also advises charge nurses not to underestimate the role. “You’re in charge of the flow of the whole unit,” says the staff nurse who frequently works as a charge nurse in the San Francisco General Hospital Birth Center. “You have to make sure everything goes smoothly. You have to anticipate that things might happen.” Prevent small problems from becoming major incidents by maintaining clinical skills, knowing the facility’s policies and procedures, and not hesitating to go up the chain of command when necessary, she suggests.

Boyle speaks from experience. She remembers one time when she was a charge nurse when she and the bedside nurse disagreed with the doctor’s plan of care for a patient regarding the use of oxytocin (Pitocin). “It went against our protocol,” she says. Talking with the attending physician did not yield satisfactory results, so they moved up the chain of command and called in risk management. “We worked out a plan among all of us that we felt comfortable with,” she says. Most importantly, she notes, going through proper channels and addressing the issue before it became a problem helped facilitate patient safety and a favorable outcome.


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Anne Federwisch is a freelance writer. To comment, e-mail

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