A qualitative study of charge nurse competencies

A qualitative study of charge nurse competencies

Lynne M. Connelly

Effective nursing leadership is paramount in the modern health care setting, where complex, high-acuity inpatients are the norm. The best clinical leaders possess competencies in a variety of cognitive and behavioral areas. The charge nurse role evolved from a need to have unit leaders other than the head nurse manage patient care in the absence of the head nurse or during evening and night shifts. The charge nurse role is critical because of current staffing issues, the use of agency and/or foreign nurses, and the need for a proficient nurse to be accountable for issues arising in the unit. In short, charge nurses must take ownership for all unit activities during their shift.

Effective charge nurses mesh administrative, educational, and clinical expertise with an understanding of basic leadership principles (Cartier, 1995). Charge nurses generally come from the most obvious pool of nurses, clinical staff nurses. Unfortunately, these nurses are often academically and administratively unprepared to assume clinical leadership positions (Cartier, 1995).

Unprepared charge nurses create problems of first-line leadership, such as failure to adequately supervise other staff. Quality can be affected, especially in areas where the most acutely ill patients receive care. Orienting nurses to the charge nurse role and planning leadership education courses can be difficult because few clearly delineated competencies appear in the literature. Because there is a lack of research, or even current, general information concerning this clinical role, a study was conducted to determine the competencies necessary to be a successful charge nurse. The findings from the research are presented along with application for current practice.

Background

Although many hospitals use charge nurses, there is a lack of clear guidelines concerning the role, competencies needed for optimum role performance, and criteria for evaluating performance. Many recent articles offer advice to the new charge nurse (Costello-Nickitas, 1997; Shermont & Russell, 1996; Sonnenberg, 1999), to managers about the role (Zimmerman, 2000), or about the legal responsibilities of the team leader and charge nurse based on litigation (Mahlmeister & Koniack-Griffin, 1999).

In one of the few studies about the role, Bostrom and Suter (1992) examined charge nurse decision making concerning patient assignments. They concluded that experienced charge nurses considered more factors in making assignments and relied less on the acuity system than did novice charge nurses. Some authors have described the role of the charge nurse as multifaceted, including duties of patient care, hospital protection, and staff interaction. In an Australian survey study, Chaboyer, Najman, and Dunn (2001) found no difference between Level I (staff nurses) and Level Il/Ill (charge nurses) on perceptions of cohesiveness in their interactions with each other in the working environment at three large, tertiary care hospitals (N=555). All nurses reported a moderate amount of cohesion among themselves.

Overall, the charge nurse has been considered to be responsible for maintaining appropriate standards of care and professional staff/patient interactions (Hinkle & Hinkle, 1977). Now, with increasing patient acuity levels and shorter hospital stays, the role of the charge nurse has become integral to optimum patient care in moderate-to-large sized medical facilities throughout the United States, especially in military facilities. In addition, this position often provides the first opportunity for exercising the leadership skills that nurses will use throughout their careers. Therefore, identifying the competencies is needed by the charge nurse for achieving effectiveness in this role and was the aim of the study reported in this article.

Conceptual Framework

Competencies were conceptualized as the expectations that professionals have for a particular role. Therefore, it was considered appropriate to interview nurses at various levels who interact with charge nurses to determine the competencies for that role. Generally, qualitative researchers do not propose a framework to guide the research prior to a study. The researchers desire to stay open to what the informants are saying and develop a theory based on the research. In this study, researchers took a slightly different approach. In order to provide a starting point for the semi-structured, open-ended interview questions, they used Katz’s (1974) three broad categories of management skills–technical, human, and conceptual–to form the initial interview questions. For example, one question was, “What technical skills do you think a charge nurse needs to possess?” However, informants were allowed to explore what they perceived to be important to the subject of charge nurse competencies.

Methodology

An exploratory, qualitative research design was used in this study. The research question was: “What do nurses at various levels perceive to be the competencies needed to effectively carry out the role of charge nurse in a military medical center?” Although military nursing has certain differences when compared to civilian nursing (such as readiness to deploy and functioning in a variety of settings), the research team believed the study would have applicability to both military and civilian nursing. A stratified, purposive sampling technique (Patton, 1990) was used to select a heterogeneous group of informants representing each level of nurses (staff, charge, head nurse, supervisory) from a variety of different clinical areas until there was saturation of data categories. As mentioned above, competencies were conceptualized as the expectations that professionals have for a role; therefore, it was important to include a wide range of people involved with the role. In addition, a qualitative interview approach was thought to be the best means of exploring expectations people had for the role.

A total of 42 interviews were conducted to ensure all management levels of nurses were included, as well as a variety of intensive care, medical, and surgical inpatient units. The participants included staff nurses (11), charge nurses (12), head nurses (10), and nursing supervisory personnel (9) assigned to a military medical center in the Southwest. Interviews continued until data saturation was reached. The sample consisted of 33 females and 9 males with an average of 8 years experience (median=5; range=1-25 years). Most participants had a BSN (64%) or MSN (29%). The participants had an average of 5 years of charge nurse experience, ranging from less than a year to 22 years. Head nurses in the study had an average of 6 years of management experience. All informants gave written informed consent and the study was approved by the hospital’s institutional review board.

During the piloting of the questions, the word conceptual was changed to organizational because the informants did not seem to understand it when asked about competencies in the interviews. Katz (1974) defined conceptual skills as “the ability to see the enterprise as a whole; it includes recognizing how the various functions of the organization depend on one another, and how changes in any one part affect all the others” (p. 93). The research team believed that organizational skills fit that category.

The informants also described personal organizational skills related to time management as well as organizational skills related to understanding the entire hospital. This probably reflects the level of management with which the charge nurse is concerned. As the study progressed, the research team found that a modified group of broad categories of skills worked better for understanding charge nurse competencies than those posited by Katz (1974). In addition, informants shared a set of characteristics they thought charge nurses should possess. These adaptations will be covered in the results section.

Descriptive qualitative methodology using constant comparative analysis was used to analyze the interviews (Crabtree & Miller, 1992). This interpretative process of analysis looks for similarities and differences in narrative data. The analyst identifies underlying uniformities in the data and produces coded categories or concepts. Each category/concept is then compared to more data and to other categories/concepts to sharpen the understanding of the concept and to look for alternative interpretations (Katz, 1974).

In this study, methodological rigor was maintained by the use of standard qualitative techniques, specifically an audit trail, process and analytic memos, peer-briefing procedures, and member checking. An audit trail is the process of maintaining records of the study by documenting in memos the process and analytic decision making throughout the process. Peer briefing was conducted with periodic meetings of colleagues knowledgeable about the topic and qualitative research. This process helped prevent early closure and reduced biases the team may have had. Member checking is the process of asking informants to discuss the findings of the study and validate if the findings are representative of their experience. Member checking was accomplished by having a small number of nurses, similar to the interview informants, meet as a group. They were asked to review the codes representing charge nurse competencies, and indicate if each should or should not be included in a list of competencies of charge nurses.

Results

In analyzing the data from the interviews, the authors identified 54 specific competencies that were grouped into four categories: clinical/technical (15), critical thinking (13), organizational (9), and human relations skills (17). Specific competencies for each category are included in Table 1. After the competencies were identified, the authors further clarified each competency. A competency statement was developed, along with a paragraph clarifying the competency as an expectation of the charge nurse, and representative quotes from the interviews were provided (see Table 2). In addition to clarifying the competencies, the quotations help to illustrate how the competency was grounded in the interview data.

Themes and Discussion

Based on the findings of this study, the charge nurse role meets the definition by Katz (1974) of an administrator: “The administrator is one who (a) directs the activities of other persons, and (b) undertakes responsibility for achieving certain objectives through these efforts” (p. 91). The charge nurse directs the staff of a nursing unit for a particular shift, undertaking responsibility for the objective of providing appropriate nursing care for unit patients. Review of the literature clearly indicates that this role is not often considered an administrative or managerial position. Consistently, the head nurse is considered the entry level or first-line nurse manager (Beaman, 1986). Participants in this study saw the charge nurse as the front-line manager as described in the following passage:

The charge nurse equates to

the on-the-ground leader;

(the) front-line person who

has the responsibility and

hopefully the capability to

assess the day-to-day situation

and initiate the actions

needed to take care of the

issues at hand, operationally

day-to-day. They probably

don’t have the need to be

much of a forward thinker, not

too much strategic planning,

(but) the really operational,

tactical on the ground, ready

to go. But dealing with every

issue that comes up and facilitating

the things that are necessary

to make the ward run

correctly, as well as making

sure that the patients get the

first-line care that they need.

This quotation identifies the charge nurse as problem-solver and manager of the quality of care delivered on a particular shift. As noted earlier, a great deal of attention has been paid to the head nurse role, and this study is not intended to minimize the importance of that role. However, on a daily, shift-by-shift basis, the charge nurse has direct responsibilities that are both clinical and operational in nature. This is clearly supported by the nature of the competencies identified in this study. Frequently charge nurses have only the preparation they have received in their formal education. As noted by Beaman (1986) and Stevens (1980), education for management has been eliminated from many schools’ curricula. Charge nurses clearly need further development for their managerial role.

Because charge nurses have a tremendous amount of responsibility, the nursing profession may need to examine closely the expectations and types of support nursing leaders provide to individuals in charge nurse roles. The findings of this study agree with a great deal of the literature concerning the role of administrators and first-line managers, although little of that literature is research based (Noll, Hix, & Hawley, 1989; Osguthorpe, 1997).

One of the major themes of this study was the importance of human relations competencies. This is supported in the literature about management, as well as the literature about retention. For example, a study of two 500-bed hospitals found the most satisfying attributes of nurses’ jobs were positive relationships with the supervisor and co-workers (Longo & Uranker, 1987). In a qualitative study of nurse retention, Connelly, Hoffart, and Taunton (1997) found the reason most frequently mentioned by nurses for staying in their position was cohesive coworkers. The second most frequently mentioned reason was the atmosphere of the unit or hospital. Furthermore, charge nurses play an important role in determining the atmosphere and teamwork of a unit. This is reflected in the following quote from this study: “Trying to have a cohesive atmosphere, too. And I really think units function so much better if everybody looks at it as, you know, a joint effort … the atmosphere is teamwork …”

Making the best use of all resources, whether on the unit or in other areas, was another theme in this study. The nurses who were interviewed frequently mentioned the need for charge nurses to know their available resources and how to use them to facilitate patient care. As one charge nurse said:

That means having the basic

knowledge, but not necessarily

knowing it all … And also

knowing who their resources

are. In the organization you

can be a charge nurse when

you’re fairly junior as long as

you know who’s available to

help you out if you get yourself

in a corner.

This thought is consistent with the views of Bostrom and Suter (1992), who indicated that assigning nursing resources to individual patients was an important function of charge nurses.

In addition, having the ability to use critical thinking skills to troubleshoot and think ahead has become increasingly important. One comment from this study that reflects the ability to think critically is, “I guess you have to triage the situation, if you will, meaning you have to ultimately decide what has to happen for the patient and work backwards.” The duties of the charge nurse have expanded as the acuity of the patient population has increased, technology has become more complex, and the quick turnover of patients has made rapid problem solving the norm (Noll et al., 1989). Also, leaders within health care organizations expect nurses to be intelligent stewards of the various resources within their management control.

In addition to the importance of using human relations skills and making the best use of available resources is the crucial relationship between the head nurse and charge nurse. Head nurses stated that charge nurses represented them on a particular shift, that they were an “extension of the head nurse.” Understanding the philosophy of the head nurse was important in order to support the head nurse’s policies: “If the head nurse feels that we will bend over backwards and go that extra mile for our patients, then the charge nurses usually accept that and go with it.” Mutual respect, trust, and constant communication are necessary for both to do their job effectively. In addition, the head nurse is responsible for developing, coaching, and teaching the charge nurse. As one head nurse asserted, “And they tend to get molded (by) their head nurse, I think you (head nurse) play a big role in that.” The following quotation illustrates the importance of the relationship between the head nurse and the charge nurse, and how assessment of a charge nurse’s abilities can be accomplished:

Then she was talking about a

nurse, a charge nurse, who

she described as a natural

charge nurse, was the words

that were used. And it was a

young, newer nurse that

wouldn’t be expected to have

good charge nursing skills and

this was a time when (name)

was a head nurse, and this

new nurse insisted that she

was ready to be charge, but

she wasn’t sure that (the new

nurse) was (ready). So she

allowed her to be charge on

weekends, but then came in

and supervised her (when)

she was charge nurse. And

questioned her, ‘Why are you

doing that?’ ‘What are you

thinking about?’ ‘How are you

going to do that?’ So just trying

to ascertain (the new

nurse’s) knowledge about

what was going on and (the

head nurse) said the maturity

level that (the new nurse) had,

was very interesting. This was

a very organized person; the

thing that gave her the most

confidence was that this

charge nurse knew when to

call for help, knew when to

call the physician, when there

was something that was not

right. So (the new nurse) had

early signs of clinical expertise

in terms of looking at the

cues a patient would be presenting

physically and interpreting

those properly to

know when she (was) going to

be needing assistance and to

call a physician for it.

Characteristics of an Effective Charge Nurse

In addition to the competencies, study participants provided a description of 15 characteristics an effective charge nurse should possess. Rather than specific competencies, they are similar to personal traits or attributes. An individual may be able to develop some of these over time, but they are more difficult for others to teach or develop in another person. The principal criterion for a competency must be effective action under varying conditions (Katz, 1974). In addition, a competency should be a skill that can be developed as opposed to characteristics, which are traits or attributes an individual possesses at a point in time. Many of the characteristics mentioned were seen as prerequisites for the charge nurse role. Some of the nurses who were interviewed thought a head nurse would be wise to assess these characteristics in nurses assigned to the position of charge nurse. The characteristics were:

* Accountability

* Assertiveness

* Positive attitude

* Authority

* Confidence

* Need to control

* Fairness

* Flexibility

* Humor

* Image

* Initiative

* Maturity

* Ability to learn from mistakes

* Command respect

* Responsibility

The characteristics, along with the competencies, provide a detailed examination of what is in the charge nurse role. Figure 1 outlines the relationships among characteristics, competencies, and developmental programs.

[FIGURE 1 OMITTED]

Modification of Conceptual Framework Based on Data

At the beginning of the study, Katz’s (1974) three categories of administrative skills (technical, conceptual, and human relations) were used as the basis of probing questions in the interviews. As previously mentioned, the word conceptual was changed to organizational. Katz’s (1974) three categories of administrative skills did not fully account for all the data. After reviewing the data, the research team decided to add the category of critical thinking because this category reflects many things charge nurses do and defines an area that new graduates clearly need to develop. In one study that used Katz’s categories, the technical skills category was used very broadly, including critical thinking (Duffield, 1994). However, a broad approach to technical skills did not appear to provide sufficient explanation in light of the data for the current study. Cartier (1995) supported the idea that critical thinking is part of the charge nurse role: “Critical thinking and expanded decision-making skills, as well as increased delegation to peers and subordinates, would be required of staff nurses acting as (charge nurses)” (pp. 277-278). The categories in Table 1 are a useful way to group and think about the competencies when charge nurse skills are being developed; each area can be developed in a variety of ways as outlined in the next section of this article.

Developmental Programs

Educational and developmental programs are needed for charge nurses, especially those who are relatively new graduates. Based on findings of this study, educational programs should include role playing, analysis of cases, and debriefing specific situations. Although some didactic information is important, it is perhaps more important for charge nurses to practice handling certain problematic situations and receive feedback from a supportive person. The number of human relations skills competencies demonstrates the importance of this category. Charge nurses need these skills, which will also be needed throughout a nursing management career. The data from this study are rich with descriptions of effective and ineffective charge nurses. Material from the interviews of nurses at any facility could be used in writing educational scenarios that will be helpful in developing effective training programs for charge nurses in various settings.

New charge nurses commented that a checklist of critical tasks would be beneficial. They believed such checklists could assist them in organizing the required duties of the shift. Examples of items on such a checklist could include checking emergency equipment, recording patient acuities, and checking the schedule of the oncoming shift to assure staffing to prevent later problems. The charge nurse would not have to perform all the tasks but would need to assure that duties are assigned to staff members and accomplished by the end of the shift. As junior charge nurses mature in their roles, they no longer rely on such lists. However, a list initially provides a framework for them to manage or assign essential tasks.

Developmental relationships, especially with the head nurse, are very important to help mold charge nurses. Because the charge nurse represents the head nurse on a particular shift, it is critical they understand each other and work as a team. Therefore, it is essential that head nurses clearly communicate their philosophy for care provision and the expectations related to assuming and successfully performing the charge nurse role. In addition, the charge nurse role is an important developmental role for a nurse aspiring to become a head nurse because the best performers of the charge nurse role are often selected for advancement opportunities.

Conclusion

The charge nurse role is complex and serves as the clinical nurse’s exposure to first-line management. This study fills a major gap in the literature by providing research-based information about the role of the charge nurse. The number and complexity of the identified competencies reflect the importance of this role in hospitals. Further work is needed in the areas of appropriate selection of nurses for the role, training programs, coaching relationships with the head nurse, and recognition programs for those who excel in the role. Although this study was conducted in a military setting, the findings clearly have applicability to most settings that use the charge nurse position. The competencies outline specific leadership skills that any charge nurse either possesses or needs to develop to be effective in the role.

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1. Discuss the role of charge nurses in hospital settings.

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3. Describe a competency statement.

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Table 1. Charge Nurse Competencies

Clinical/Technical Competencies: Responsibilities directly related to patient care or some technical aspect of working on a clinical unit.

1. Calculate patient acuities and enter them in the computer (or ensure these are done).

2. Complete administrative duties (examples: complete 24-hour report, pre-op charts, update board).

3. Assist staff in completing their work.

4. Act as a clinical resource, sharing knowledge.

5. Use computer skills to chart and complete reports.

6. Delegate workload appropriately and fairly.

7. Check emergency equipment, handle unit emergencies.

8. Conduct initial unit-wide patient assessments.

9. Use knowledge of medical equipment to provide care.

10. Use knowledge of available clinical resources when needed.

11. Use knowledge of unit, type of patients, procedures, etc., to plan work.

12. Maintain a safe, clean physical unit environment.

13. Provide direct patient care as needed, balancing patient care with charge nurse duties.

14. Give an effective change of shift report.

15. Provide for patient safety.

Critical Thinking Competencies: Responsibilities that address effective decision making and problem solving involving both clinical and operational issues on the unit.

1. Anticipate patient needs, staffing requirements; engage in anticipatory planning and generating solutions.

2. Assess/evaluate clinical and operational information.

3. Manage crises as they occur.

4. Make decisions.

5. Use good judgment.

6. Prioritize–decide the order of importance of tasks.

7. Use knowledge of patient status to plan care.

8. Use knowledge of staff capabilities to plan care.

9. Troubleshoot–problem solve to prevent a potential crisis.

10. Manage time effectively.

11. Assess requirements and take action to provide adequate staff.

12. Know and deal with personal limitations.

13. Deal effectively with change.

Organizational Competencies: Responsibilities to understand and operate in the organizational environment on the unit as well as in the larger institutions (hospital, agency, etc.).

1. Coordinate multiple tasks in order to keep unit operations flowing.

2. Deal with interruptions.

3. Use a method to keep organized.

4. Prepare prior to the beginning of shift.

5. Know and use hospital/unit policies and patient procedures appropriately.

6. Oversee unit functions to ensure overall quality of care/practice.

7. Understand what is happening in whole hospital in order to adjust running the unit.

8. Manage cost and supply issues.

9. Accept the primary role of the charge nurse.

Human Relations Skills Competencies: Responsibilities to interact effectively with other personnel to accomplish the requirements of patient care as well as administrative activities.

1. Be accessible–identify self as the charge nurse.

2. Influence atmosphere of unit in positive manner.

3. Demonstrate caring for others.

4. Communicate effectively with head nurse, on-going/off-going shift, physicians, patients/families, staff, supervisors.

5. Deal with difficult people, situations, shifts.

6. Use diplomacy with people.

7. Get along with people.

8. Interact positively with head nurse.

9. Provide leadership during the shift.

10. Motivate staff to accomplish the mission.

11. Protect staff.

12. Address patient complaints.

13. Role model effectively.

14. Supervise the work of the nursing staff (including agency nurses).

15. Develop and train the staff.

16. Support staffs personal needs.

17. Team-build–develop cooperative efforts.

Note: This research (TSNRP #N96045) was sponsored by the TriService Nursing Research Program, Uniformed Services University of the Health Sciences. The information or content and conclusions do not necessarily represent the official position or policy of, nor should any official endorsement be inferred by, the TriService Nursing Research Program, Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. Government.

Table 2.

Example of a Competency Statement

Title of Coordinate multiple tasks in order to keep unit

Competency operations flowing.

Category Organizational skills

Statement The charge nurse is responsible to ensure operations

on the unit flow smoothly, multiple tasks are handled

simultaneously, and patient/staff/ancillary support

traffic is coordinated so all required tasks are

accomplished.

Explanation The charge nurse must be able to coordinate not only

the care of individual patients, but also the

operations of the unit. This is evidenced by the

charge nurse’s ability to communicate and negotiate

with other professionals, units, and departments in

the hospital, as well as his/her own staff. This may

be the coordination with physicians to discharge

patients in order to “make room” for new patients or

negotiation with other units on when to receive

patient transfers. This also involves working with the

staff on the unit to ensure they have the support they

need to complete all care.

Representative * “Make sure your patients get to the right place at

Quotes the right time.”

Kind of triage nursing.”

* “Organizational flow of patients through the unit

and working with physicians to get patient flow can

be hectic and tedious.”

* “You can talk to them and negotiate a time for those

patients (to) come in, so that then you have at

least the ability to control the traffic coming into

your ward.”

* “They (charge nurses) will be facilitating care

between the medical staff, the ancillary staff, all

the other services, you know, whether it’s physical

therapy, nutrition care, any of those, social work,

what ever happens to be needed.”

References

Beaman, A. (1986). What do first-line nursing managers do? Journal of Nursing Administration, 16(5), 6-9.

Bostrom, J., & Suter, W. (1992). Charge nurse decision making about patient assignment. Nursing Administration Quarterly, 16(4), 32-38.

Cartier, T. (1995). Development and implementation of a leadership skills course for the charge nurse. The Journal of Continuing Education in Nursing, 26(6), 276-279.

Chaboyer, W., Najman, J., & Dunn, S. (2001). Cohesion among nurses: A comparison of bedside vs. charge nurses’ perceptions in Australian hospitals. Journal of Advanced Nursing, 35(4), 526-532.

Connelly, L.M., Hoffart, N., & Taunton, R. (1997). Why nurses stay: A qualitative study. Surgical Services Management, 3(5), 44-48.

Costello-Nickitas, D.M. (1997). Get ready to take charge. American Journal of Nursing, 97(5), 16B- 16J.

Crabtree, B., & Miller, W. (1992). Doing qualitative research. Newbury Park, CA: Sage.

Duffield, C. (1994). Nursing unit managers: Defining the role. Nursing Management, 25(4), 63-67.

Hinkle, M.J., & Hinkle, B.J. (1977). Priorities of the charge nurse B Part I. Supervisor Nurse, 8(11), 47-54.

Katz, R. (1974). Skills of effective administrators. Harvard Business Review, 52(5), 90102.

Longo, R., & Uranker, M. (1987). Why nurses stay: A positive approach to the nursing shortage. Nursing Management, 18(7), 78-79.

Mahlmeister, L., & Koniack-Griffin, D.K. (1999). Professional accountability and legal liability for the team leader and charge nurse. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 28(3), 300-309.

Noll, M., Hix, C., & Hawley, D. (1989). Re-evaluating the role of the charge nurse. Dimensions of Critical Care 8(5), 298-309.

Osguthorpe, S. (1997). Managing a shift effectively: The role of the charge nurse. Critical Care Nurse, 17(2), 64-70.

Patton, M.Q. (1990). Qualitative evaluation and research methods. Newbury Park, CA: Sage.

Shermont, H., & Russell, G. (1996). Making assignments that really work. American Journal of Nursing, 96(1), 16M-16N.

Sonnenberg, D. (1999). Life in the fast lane-helpful tips for OR charge nurse. AORN Journal, 69(5), 941-944.

Stevens, B. (1980). Improving nurses’ managerial skills. Nursing Times, 76(46), 2022.

Zimmerman, P.G. (2000). Charge nurse (Manager’s Forum). Journal of Emergency Nursing, 26(2), 164-165.

Lynne M. Connelly, PhD, RN, is a Colonel (Ret.), Army Nurse Corps, and an Assistant Professor, University of Texas Health Science Center, School of Nursing, San Antonio, TX.

Linda H. Yoder, PhD, MBA, RN, AOCN, is a Colonel (Ret.), Army Nurse Corps, and was assigned as the Senior Nurse Researcher, Walter Reed Army Medical Center, Washington, DC, at the time this article was written.

Denise Miner-Williams, MSN, RN, was a Research Associate on this study and is presently a Doctoral Student, University of Texas Health Science Center, School of Nursing, San Antonio, TX.

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