Stress among Charge Nurses: Tool Development and

Stress Measurement
Hanna Admi, PhD, RN; Yael Moshe-Eilon, PhD, RN

Posted: 09/17/2010; Nurs Econ. 2010;28(3):151-158. © 2010 Jannetti Publications, Inc.

Abstract and Introduction

Introduction

Changes in health care systems, including the international shortage of nursing staff, have implications on role
stress felt by nurses, especially by nursing managers. In a review of 68 articles on nurses' role stress, the most
frequently identified stressors were workload, role conflict, ambiguity, and lack of support (Chang, Hancock,
Johnson, Daly, & Jackson, 2005). Stress leads to job dissatisfaction, burnout, and absenteeism; also, negatively
impacts patients (Aiken et al., 2001; Lee & Henderson, 1996).

Most research has focused on traditional and general role stressors, measured by standardized tools. Studies of
the specific stressors unique to nursing roles are few. One such role is the managerial role of charge nurses in
hospitals. Charge nurses serve on the front line of the profession. They are expected to be responsible
simultaneously for three separate groups of clients: patients, nursing staff, and multi-disciplinary staff. The
charge nurse has a central role in patient outcomes and safety, the well-being of the nursing staff, liability
prevention, and managing a multi-disciplinary team (Doherty, 2003; Sherman, 2005).

Though a complex and challenging position, the role of the charge nurse has received little attention in nursing
literature compared with other nursing leadership positions (Connelly, Yoder, & Miner-Williams, 2000; Miner-
Williams, Connelly, & Yoder, 2000; Sherman, 2005).

The objectives of this study were:

1. Develop a specific tool for measuring the stress of charge nurses in hospitals.
2. Assess the level of stress of charge nurses.
3. Explore the relationship between stressors and demographic characteristics (age, seniority, and
education).

Literature Review

In their review of 100 studies, Lambert and Lambert (2001) found the following to be associated with nurses'
role stress: high job demands; low supportive relationships; dealing with death and dying; work overload;
uncooperative family members and clients; inability to reach physicians; unfamiliarity with situations; concern
for the quality of nursing staff, medical staff, and patient care; inability to deliver quality nurse care; time
demands; state laws restricting the ability to carry out the advanced practice role; poor relationships with
supervisors, co-workers, and physicians; and low organizational commitment.

According to Lazarus and Folkman (1984), stress is a complex multi-dimensional phenomenon focusing on a
particular dynamic relationship between a person and his/her environment. They proposed that stress is
determined by a person's subjective perceptions and interpretations of a given transaction as taxing or exceeding
his/her resources and endangering his/her well-being. In applying this theory to the charge nurse, we focus on
the demands of the role and on nurses' resources such as competencies, knowledge, clinical experience, and
social support.

The charge nurse is responsible for a hospital patient care unit during the evening and night shifts in the absence
of the nurse manager. This role is critical, particularly considering workforce shortage and the high demands for
nurse proficiency. The charge nurse is responsible for the proper function of the unit during the shift, and for
maintaining appropriate standards of care and professional staff/patient interactions. This position often
provides the first opportunity for formally exercising the leadership skills that nurses use throughout their
careers (Connelly et al., 2000; 2003).

Stress among Charge Nurses

The charge nurse is required to use managerial as well as clinical expertise (Connelly et al., 2003; Sherman,
2005). Charge nurses are expected to always be available, to be in control of all activity taking place in the
patient care unit, and to serve as role models to the staff (Castledine, 2001).

Recently, additional demands have been added to the charge nurse position in many organizations: proficiency
in computerized nursing records, coordination of the activity of the unit as a whole, and clinical expertise in a
specialized field of nursing. The charge nurse is expected to be clinically competent, to assess patients
thoroughly, to plan patient care, and to evaluate nursing interventions based on evidence, protocols, and
procedures (Castledine, 2001). The charge nurse is not expected to supervise the bedside work of the staff
nurses in the patient care unit, but to provide advice and support when his/her expertise is required (Endacott,
1999). Critical thinking skills enable charge nurses to troubleshoot and think ahead (Connelly et al., 2000).
Other important role demands and expectations are the ability to prioritize the workload; to become an active
member of an emergency team; to assist staff members with heavy or difficult assignments; to deal
empathetically with family members; to communicate effectively with medical staff members, peers, and other
health care professionals; to solve dilemmas of conflict management; and to foster team building (Ambrose,
1995; Sherman, 2005). The role requires making difficult and potentially unpopular decisions, such as assigning
a new admission to an overburdened staff nurse (Connelly et al., 2000).

The high stress inherent in the charge nurse position is apparent. Frequent decision making, regular
interruptions, and high expectations for constant availability and assistance make it one of the most stressful
roles in nursing (Connelly et al., 2000). Though the stress factors mentioned here are felt by all nurses, they
may be most strongly experienced by the charge nurse, due to his/her accountability for leadership activity in
the absence of the nurse manager during shifts. Therefore, we hypothesized that the main stress factors on
charge nurses are role specific.

Methods

Design

This quantitative descriptive study identified stress factors related to the role of the charge nurse. Data were
collected via an anonymous self-completed questionnaire among charge nurses and nurse managers at the
largest tertiary hospital (900 beds) in the northern region of Israel.

Sample

Table 1 presents the demographic characteristics of a convenient nursing sample obtained from all the patient
care units at the hospital (N=45). Of 215 charge nurses, potential charge nurses, and nurse managers who
consented to reply voluntarily and anonymously, 129 nurses completed the study's questionnaire (60% response
rate). The inclusion criterion was the completion of a preparedness program for charge nurses. The sample
characteristics are representative of the intended hospital staff population.

Table 1. Demographic Characteristics (N = 129)

Gender    16–20 years 9 (7%)

   Male 22 (17%)    20+ years 18 (14%)
   Female 105 (81.5%)    Missing 1 (0.8%)
   Missing 2 (1.5%) Seniority as Charge Nurse
Age    None 32 (24.8%)
   Up to 30 years 53 (41.1%)    Up to 1 year 19 (14.7%)
   31–40 years 42 (32.6%)    2–5 years 31 (24%)
   41–50 years 20 (15.5%)    6–10 years 7 (5.4%)
   51–60 years 13 (10.1%)    11–15 years 10 (7.8%)
   Missing 1 (0.8%)    15+ years 24 (18.6%)
Hospital Patient Care Units    Missing 6 (4.7%)
   Oncology 13 (10.1%) Job Partiality
   Internal medicine 34 (26.4%)    Full-time job 76 (59.4%)
   Psychiatry 3 (2.3%)    Part-time job 52 (40.6%)
   Surgery 25 (19.4%)    Missing 1 (0.8%)
   Operating room 6 (4.7%) Post-Graduate Clinical Course
   Intensive care 18 (14%)    With 58 (47.5%)
   Maternity & Gynecology 15 (11.6%)    Without 64 (52.5%)
   Pediatrics 11 (8.5%)    Missing 7 (5.7%)
   Missing 4 (3.1%) Professional Education
Professional Seniority    RN 25 (19.4%)
   Up to 5 years 48 (37.2%)    RN + BA 81 (62.8%)
   6–10 years 21 (16.3%)    RN + MA 22 (17.1%)
   11–15 years 11 (8.5%)    Missing 1 (0.8%)
   16–20 years 14 (10.9%)
   20+ years 21 (16.6%)
   Missing 14 (10.9%)
Seniority in the Current Clinical Field
   Up to 5 years 71 (55%)
   6–10 years 18 (14%)
   11–15 years 12 (9.3%)
Instrument

The charge nurse stress questionnaire (CNSQ) was developed through a five-step process.

1. Focus groups of charge nurses, each comprising seven to nine participants representing different hospital
units, were held. Through semi-structured interviews, aspects of the charge nurse role were revealed. For
example, participants were asked to describe their feelings, thoughts, and concerns felt from the moment
they knew they were assigned as charge nurse, and throughout the shift. All sessions were tape-recorded.
The nurses signed informed consent for participation in the focus group and for the tape-recording of the
sessions.
2. Through in-depth individual interviews conducted with seven charge nurses, topics raised in the focus
groups were investigated.
3. Fifty-nine statements were selected for assessment of aspects of stress on a 5-point Likert scale
(1=strongly disagree, 5=strongly agree). The second part of the questionnaire included demographic
characteristics. Nurses with clinical and academic expertise reviewed and revised the questionnaire.
4. A pilot study was conducted on a sample of 51 nurses. From the results, the questionnaire was revised to
a final CNSQ version comprising 50 statements.
5. Using factor analysis, six factors were designated: authority-responsibility conflict, patient-nurse
interaction, deficient resources (time, people, equipment), managerial decision making, role conflict, and
overload (physical and emotional). Table 2 presents examples for each of these factors.

Procedure

The CNSQ questionnaire was distributed to all 215 charge nurses, unit nurse managers, and potential charge
nurses at the largest tertiary hospital, in the northern region of Israel, with 900 beds and 45 patient care units.
The tool was self-administered anonymously. Together with the questionnaire, the nurses received a letter
explaining the study. Institutional review board approval was obtained.

Data Analysis

Data were analyzed using SPSS software, version 12 (SPSS Inc. Chicago, IL). Non-parametric Mann-Whitney
U test and Kruskal Wallis statistics were used since the distributions for many of the statements were not
normal. Pearson correlation coefficient was used to analyze relations among the factors.

Results

The Charge Nurse Stress Questionnaire (CNSQ) – Tool Development

The CNSQ comprises 50 statements of stress-evoking situations typically faced by charge nurses. Table 3
shows the inter-factor correlations between the six stress factors addressed by the CNSQ: authority-
responsibility conflict, deficient resources, role conflict, patient-nurse interaction, overload (physical and
emotional), and managerial decision making.

Table 3. Inter-Factor Correlations (significant at the 0.01 level)

Authority- Managerial
R (Pearson Deficiency of Role Patient-Nurse
Responsibility Overload Decision
Correlation) Resources Conflict Interaction
Conflict Making
Authority- 0.809 0.807 0.819 0.748 0.752
Responsibility
Conflict
Overload 0.829 0.789 0.774 0.763
Deficiency of
0.777 0.762 0.733
Resources
Managerial
0.764 0.711
Decision Making
Role Conflict 0.736
Patient-Nurse
Interaction

The moderate-to-high correlation between factors implies that the six factors identified represent themes of the
same area under discussion. The mean stress level measurements were low for all the factors (see Table 4). The
internal consistency coefficient of each factor (α Cronbach) ranged between 0.71–0.90. These moderate-to-high
values indicate reliability of the measurement tool. In addition, the low standard deviation of each factor
indicates low measurement error.

Table 4. Stress Factors – Mean and Standard Deviation (SD)

Mean ± SD (scale: α Corrected Item to Total

Factor
1–5) Cronbach Correlation Range
Managerial decision making 2.70 ± 0.75 0.91 0.52–0.75
Authority-Responsibility conflict 2.68 ± 0.69 0.76 *0.24–0.55
Deficient resources (time, people,
2.68 ± 0.68 0.75 *0.26–0.54
equipment)
Role conflict 2.62 ± 0.74 0.72 0.41–0.54
Patient-Nurse interaction 2.62 ± 0.77 0.78 0.45–0.71
Overload (physical and emotional) 2.46 ± 0.66 0.83 0.41–0.59

* Low correlation

None of the demographic characteristics predicted the stress level of the charge nurses. Together these
parameters predicted only 10% of the variance.

No significant difference was found in the means of the six factors investigated between acting charge nurses
and nurses who are intending to perform this role (see Figure 1). The mean levels of stress were significantly
higher for nurses who attended post-graduate clinical programs than for those who did not (see Figure 2)
Figure 1.  Comparison of Stress Levels Between Acting Charge Nurses and Pre-Acting Charge Nurses

Figure 2.  Comparison of Stress Levels Between Post-Graduated Nurses and Non-Graduated Nurses
Figure 3.  Comparison of Stress Levels Between Department Nurse Managers and Charge Nurses

Significant differences were found between department nurse managers and charge nurses in regard to two
factors: "deficiency of resources" and "authority-responsibility conflict."

Discussion

Most studies measuring nurses' stress focus on traditional and general role stressors. According to Lazarus'
conceptual theory, stress is a subjective phenomenon that is determined by one's perception and interpretation of
a specific situation. In this context, it is important to identify the stressors perceived by nurses in specific roles
and settings. However, tools measuring stressors of particular nursing roles, including the stress of different
managerial roles, are lacking.

In this study, the CNSQ, a tool to measure the stress role of charge nurses, was implemented and developed to
assess stress in charge nurses. We established the validity and reliability of the CNSQ based on experts' review,
focus groups, and statistical analysis. A moderate to highly significant inter-correlation between the six factors
assessed was achieved. Moderate Cronbach alphas on five factors (≥0.75) confirmed internal reliability of the
factors. In addition, the low standard deviation of each factor indicates low measurement error. The new tool
demonstrated appropriateness and reliability in assessing the unique stressors faced by charge nurses.

Of note, the stressors that characterize the charge nurse role are different from the commonly identified
stressors in the nursing liter ature (Chang, Hancock, Johnson, Daly, & Jackson, 2005). While workload,
ambiguity, and lack of support were the most prominent stressors in standardized tools, managerial decision
making, authority-responsibility conflict, deficient resources, role conflicts, and patient-nurse interaction were
the main stressors for charge nurses in this study. These findings support the conceptual model of stress that
guided this study (Lazarus & Folkman, 1984), namely that the prominent stressors on charge nurses are role
specific.
Multi-variant analysis did not identify significant correlations between the stress factors and the demographic
variables investigated. Parameters not tested in the current study may better predict stress level.

Stress among Charge Nurses

Overall, the stress level of the charge nurses was surprisingly moderate to low (range 2.46–2.7 on a scale of 1–
5). This relatively low stress level should be further explored. The organizational in-service training programs
may provide partial explanations by improving the ability to cope with stress.

There were no significant differences among the stress factors. Managerial decision making evoked the highest
stress level. The charge nurse is expected to have an overview of all patients on the unit, and be responsible and
accountable for their health and progress. The charge nurse must cope with conflicts within a triple loyalty:
patients, staff, and organization. The role demands familiarity with the abilities, strengths, and weaknesses of
the staff, and adaptation to the influx of admissions and ongoing events in the patient care unit. The charge
nurse must keep track of the numerous tasks to be performed on the shift, set priorities, and ensure timely
patient care. The hospital delegates to this position the nurse manager's authority of the unit. Therefore it is not
surprising that the highest stress level is due to managerial decision making and authority-responsibility
conflict.

As in the literature, deficiency of resources was another important factor of stress among charge nurses. In a
leadership role, the charge nurse often feels responsible for the consequences of deficient resources, such as
unskilled staff, missing equipment, or understaffing. Therefore, it is not surprising that deficient resources
increase the charge nurse's stress level (Castledine, 2001; Connelly et al., 2000; Mathias, 2001; Miner-Williams
et al., 2000).

The gap between role demands and available resources has personal and professional consequences.
Incompetent charge nurses may fail to supervise staff adequately, impacting staff performance and quality of
care (Connelly et al., 2003).

Stress, Post-graduate Education, and Managerial Role

Post-graduate education and managerial role had a significant impact on the stress level of the charge nurse.
Other demographic characteristics, such as age, gender, seniority, number of weekly shifts, and professional
education, did not have a significant impact.

Nurses who completed post-graduate clinical programs had a higher stress level. It seemed the more a nurse
studied and was aware of the outcomes of his/her performance, the more the nurse felt responsible and stressed.

As in other studies (Chang et al., 2005), department nurse managers perceive "deficiency of resources" and
"overload" as significantly greater sources of stress than do charge nurses.

The differences in stress between nurse managers and charge nurses support our theoretical framework. Charge
nurses perceive the threats of managerial situations differently.

Recommendations and Future Research

We consider the charge nurse to fulfill a leadership role, and not only managerial. Nevertheless, nurses may be
promoted to charge nurse based on excellent clinical performance but lack of leadership skills (Ocker, Merkel,
Ostrander, & Ferries, 1995). To develop charge nurses' leadership abilities, we propose a two-phased training
program: first, preparedness program, and later, a continuous on-the-job mentoring program. The first-phase
skills should include the reinforcement of areas of knowledge such as decision making, teamwork, conflict
management, and feedback. We suggest that senior managerial nurses lead a training program that includes
lectures and workshops using techniques such as role playing, problem-based learning, and simulations. In
addition to didactic information, acquaintance with managerial situations and feedback from a supportive group
are needed (Connelly et al., 2003).

The second phase is an ongoing training program. Recommendations in the literature emphasize the importance
of discussions that analyze typical situations (Avigne, Clark, Ingram, & Jones, 1995; Callahan & Blaney, 1995;
Connelly et al., 2003).

Based on this study, we developed a mentoring program aimed at developing charge nurses' abilities to cope
with their role demands. Charge nurses analyzed unresolved critical events from their current experiences, and
had the opportunity for emotional ventilation, peer support, and strengthening of coping skills. Feedback from
the participants' shows that the sharing of difficulties, worries, successes, and failures enhanced problem-
solving abilities. Further research is needed to explore additional innovative training programs geared to
develop leadership skills among charge nurses.

We recommend replicating this study with larger samples and with different managerial roles and settings. In
addition, cross-cultural research is needed to compare the experience of stress factors among charge nurses in
different countries.

Stress is what a person perceives as stressful in a certain situation. In this study, charge nurses experienced
stress factors specific to their role. It is the responsibility of nursing management to prepare groups of nurses to
cope with what they perceive as stressful for them and to provide ongoing mentorship. Investment in front-line
leadership will benefit patients, staff teams, the organization, and the profession.

Sidebar

Executive Summary

 The aim of this study was to develop and implement a tool for measuring the role stress of charge
nurses.
 Tools are lacking regarding measurement of nursing role stressors, particularly for charge nurses.
 Based on focus groups and in-depth interviews with charge nurses within a large tertiary hospital, a
charge nurse stress questionnaire was developed which measures six factors of stress: authority-
responsibility conflict, patient-nurse interaction, deficient resources, managerial decision making, role
conflict, and overload.
 The prominent stressors on charge nurses were specific to the role. Mean levels of stress were
significantly higher for nurses who attended post-graduate clinical courses than for those who did not.
The mean level of stress was higher for department nurse managers than for nurses without a managerial
position.
 This tool was designed to measure charge nurse stress demonstrates reliability, and highlights the
specific stressors demanded by the role. Preparation and ongoing support for fulfilling this position are
recommended.

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Acknowledgment
Nurs Econ. 2010;28(3):151-158. © 2010 Jannetti Publications, Inc. Source:
http://www.medscape.com/viewarticle/726677