What is a Nurse Leader?

Nurse leadership is defined by a nurse’s actions and does not necessarily mean the nurse is in a management or administrative position. Leaders in nursing inspire and influence others to achieve their maximum potential. They apply leadership principles and use critical thinking principles while collaborating with the health care team and advocating for quality, evidence-based client care. Nurse leaders take a broad view of how daily tasks impact the overall goals of the health care organization. They communicate expectations to their team and motivate them to achieve predetermined goals. Nurses can lead from various roles if they project the necessary leadership qualities to influence others.^[1]

Projecting leadership skills can allow a nurse to lead without being assigned a specific management position. A nurse can become involved in the following activities to project leadership^[2]:

• Seek out a mentor or become a mentor
• Volunteer for roles on committees
• Become involved in the community
• Participate in additional professional development activities
• Stay current on the latest health care trends
• Get involved with public policy

What is a Nurse Manager?

Making informed clinical decisions and advocating for clients are foundational to professional nursing practice. In addition to leadership skills required by every nurse when providing direct patient care, many nurses take on additional leadership responsibilities while managing the nursing team. Members of the nursing team include registered nurses (RNs), licensed practical/vocational nurses (LPNs/VNs), and unlicensed assistive personnel (UAP).^[3]

A registered nurse (RN) is a nurse who has completed a required program of study (i.e., associate degree, diploma, or bachelor’s degree), successfully passed the NCLEX-RN, and received an RN nursing license. The RN is considered the leader of a nursing team for an assigned group of clients. The RN follows the standards of care known as the nursing process (assessment, diagnosis, outcome identification, planning, implementation of interventions, and evaluation).

Licensed practical/vocational nurses (LPNs/VNs) complete a state-approved practical nursing program, successfully pass the NCLEX-PN, and receive an LPN or LVN license. LPNs/VNs perform basic nursing care for stable clients under the supervision of an RN. RNs may delegate nursing tasks to qualified, competent LPNs under specific situations.

Nursing assistants (NAs), a type of unlicensed assistive personnel (UAP), work under the supervision of LPNs/VNs and RNs and to whom a nursing responsibility may be delegated. In some states, nursing assistants must complete a state-approved nursing assistant training program and successfully pass the state competency evaluation to become a certified nursing assistant (CNA) to work in long-term care centers. NAs provide basic care and help clients with activities of daily living. They typically perform the following tasks:

• Measure and record clients’ vital signs and other basic measurements like input/output
• Assist clients with activities of daily living (dressing, bathing, toileting, and eating)
• Reposition and transfer clients between beds, chairs, and/or wheelchairs
• Document client behaviors and report suspected changes in condition to nurses

Nurse Leadership Roles

There are many types of nurse leadership roles, but one thing all leaders have in common is their ability to assess complex situations and effectively solve problems. Examples of common nurse manager roles are as follows^[4]:

• Charge Nurse: A charge nurse is still involved in bedside nursing but makes patient assignments for the nursing team and serves as a resource to the team. In hospitals, RNs serve as charge nurses of the nursing team. In long-term care facilities, an LPV/VN may serve as a charge nurse while also being supervised by an RN, according to their scope of practice in the state’s Nurse Practice Act. Read more about scope of practice in the “Managing the Nursing Team” section later in this chapter.
• Nurse Manager: The nurse manager serves as a supervisor of nursing team members. In hospitals, there may be one nurse manager for every patient care area in the hospital, such as the Medical-Surgical unit, Cardiac unit, Labor and Delivery unit, Surgical unit, etc.). In long-term care agencies, there may be one nurse manager for the entire facility. Nurse managers are typically RNs and, in many agencies, also have a bachelor’s degree in nursing (BSN). Responsibilities include interviewing and hiring employees for that unit’s nursing team, disciplining employees, creating work schedules, and ensuring training and continuing education requirements are met for the nursing team members on that unit.
• Director of Nursing (DON): Directors of nursing work in hospitals and other health care facilities steer the overall strategy of the nursing department. A director of nursing’s top priorities are achieving excellent patient outcomes by organizing and leading teams to ensure quality patient care and ensuring that all team members comply with state and federal regulations.
• Chief Nursing Officer (CNO): The CNO is a key leadership position that manages the budget for nursing-related items and ensures patient safety by enforcing agency policies and procedures. CNOs typically have a master’s degree in nursing (MSN).
• Health Care Administrator (CEO or VP of Nursing): There are a variety of job titles for individuals serving in the health care administrator role, including chief executive officer (CEO) or vice president (VP) of nursing. Health care administrators may have advanced degrees in nursing or other fields, such as health care administration. As the health care system moves from the former fee-for-service payment model to value-based reimbursement models, where care is reimbursed based on good patient outcomes, skilled leaders are needed in all types of health care facilities. Health care administrators may focus on a variety of priorities, such as collaborative care coordination, resource utilization, community and public health, satisfactory patient experiences, and good health outcomes.

Charge Nurses

This chapter will focus on leadership provided by charge nurses. Charge nurses oversee the operations of their specific nursing unit during a set period while working with the nursing team. The primary role of a charge nurse is to ensure that nursing functions within the department run smoothly and efficiently. They also provide guidance and support staff through challenging client care situations as they arise. Like staff nurses, charge nurses often provide direct patient care.

Typical charge nurse responsibilities include the following^[5]:

• Assign patient care to the nursing team based on acuity
• Serve as a resource to the nursing team and answer care-related questions
• Evaluate staffing plans for the following shift and call additional staff as needed
• Prioritize care for a group of clients and allocate resources as additional needs arise
• Assist with admission and discharge paperwork
• Oversee a smooth transition from one shift to another
• Check the availability of patient supplies and order additional supplies
• Provide nursing care for their assigned patients, if applicable (varies by facility)

Charge nurses who are RNs often serve as a liaison between nurses and physicians. In long-term care settings, they are the primary contact when communicating changes in patient condition and processing new orders.

Each state’s Nurse Practice Act outlines the scope of practice for LPNs/VNs functioning as charge nurses. In Wisconsin, LPNs/VNs may function as a charge nurse in long-term care facilities with the following restrictions^[6]:

• Follow written protocols and procedures developed and approved by an RN
• Manage and direct the nursing care and other activities of LPNs and nursing support personnel under the general supervision of an RN
• Accept the charge nurse position only if prepared for the responsibilities of charge nurse based on education, training, and experience beyond the practical nurse curriculum

Performing the role of a charge nurse requires ethical leadership. Nurse leaders must exhibit a strong sense of professionalism and integrity, ensuring that evidence-based nursing care is provided according to professional nursing standards. Additionally, charge nurses must be responsive to the unique needs of each individual client, recognizing that care situations are multifaceted and require tailored approaches. Furthermore, nurse leaders must ensure that clients’ rights, dignity, and cultural preferences are respected. This necessitates not only a good understanding of common medical practices but also an empathetic mindset that acknowledges the impact of social determinants of health. Through skilled coordination and communication, ethical leadership, and dedication to individualized care, charge nurses ensure that client needs are met, and optimal care is delivered. This chapter will introduce concepts related to cultivating nurse leadership, including discussing leadership styles, describing characteristics of effective leadership, and explaining conflict resolution strategies and techniques for constructive feedback. Managing the nursing team, including delegating according to the Nurse Practice Act, using prioritization strategies, and applying principles of time management will also be discussed.