What is the role of today's Chief Nursing Officer (CNO) in the medical workplace? Are there issues that need resolution within the CNO purview? Is there a turnover problem in the field when it comes to the CNO position? What leadership styles prove most effective for CNOs? These matters and others will be examined in this paper.
The Literature on Chief Nursing Officers -- Leadership Styles
As to leadership styles in nursing management, Jesus M. Casida published his dissertation for a Doctor of Philosophy at Seton Hall University on the subject of "Nurse Managers' Leadership Styles" in acute care hospitals in New Jersey. Although Casida did not use the term Chief Nursing Officer, he did employ the term "Nurse Managers" (NM) in reference to their leadership styles on "nursing units' organizational culture" (NUOC). His research included a self-administered measurement tool presented at four acute care facilities; those surveyed included 37 NMs (18 in critical care and 19 in non-critical care), and 278 staff nurses (148 in critical care; 130 in non-critical care) (Casida, 2007, p. 12). The results show that there were "positive moderately strong correlations" between transformational leadership (TL) and NUOC measures" (Casida, 12).
In fact transformational leadership was found to be a "strong predictor of mission trait culture"; on the other hand, there was a weaker correlation between transactional leadership (TR) and the nursing units organizational culture, Casida reports. And as to laissez-faire leadership, there was an overwhelming "negative" response from managers and nurses. Supervising nurses in the survey showed a preference for transformational leadership in the context of nurse managers (Casida, 12).
Mary Elizabeth O'Brien explains that nurses in the UK are comfortable with transformational leadership and servant leadership. Transformational leadership works when empowerment results "…in which all parties are allowed to work together, to the best of their ability, to achieve a collective goal" (O'Brien, 2011, p. 18). Change is needed in nurse management, O'Brien asserts, and for change to occur, CNOs and other nurse managers need to "…move away from traditional leadership practices and behaviors" and embrace transformational and servant leadership (the first duty of the manager under servant leadership is to "serve" in order to fully relate to those tasks that are expected and assure their completion by those the leader is responsible for) (O'Brien, 18).
The Literature on Chief Nursing Officers -- Turnover Problems
An article in the Journal of Healthcare Management argues that the turnover problem (with the CNO position) is very real and reflects dissatisfaction on the part of CNOs. The article presents results from a survey that got responses from 622 CNOs employed in hospitals and other healthcare facilities in the United States. The results of the survey show that 38% of those CNOs responding had left a CNO position (13% within 2 years; 25% of those within 5 years), and of the 38% some one-fourth had been asked to resign, had been "terminated," or had lost their jobs "involuntarily" (Jones, et al., 2008, p. 89).
Delving deeper into the issue of turnover in the CNO position, an earlier survey (Kippenbrock, 1995) found that there were two key reasons for CNO turnover: a) "lack of power"; and b) "conflicts with the chief executive officer" (Jones, 90). As to the survey these authors conducted, the great majority (73%) of respondents "expressed real concerns about the 'slipper slope' of CNO turnover" (Jones, 98). As to why the CNOs in the survey had left their positions, 50% were taking another CNO position; 29% wanted advancement and weren't getting it; 26% had conflicts with the CEO; 21% were simply dissatisfied with their job; and 20% said they left for "family/personal reasons" (Jones, 100).
The Literature on Chief Nursing Officers -- Key Issues They Face
According to an article in the peer-reviewed journal the International Nursing Review (Salmon, et al., 2002, p. 136) very little research has gone into the roles that the CNO must play or into the issues they face. In the first place, there is a "scarcity of literature" that relates to the role of a CNO in the global context, which is problematic, according to the authors, because the decade of the Nineties has been "…among the most chaotic ever with respect to cost-driven health reform around the world" (Salmon, 137). Given the emergence of new "and previously more controllable diseases," many civil conflicts, changing demographics and more, the CNO's task in grabbling with these issues is made more difficult because CNOs work "…largely in isolation from one another" (Salmon, 137).
The World Health Organization and the International Council of Nurses have held meetings for CNOs but as to frequent / regular opportunities for CNOs to connect with one another, these opportunities are not presented, Salmon continues (137). Hence, the authors of this article conducted a survey by sending out a questionnaire to health officials in 89 countries. The questionnaire sought to learn: a) the roles and responsibilities of CNOs; b) key issues facing CNOs; and c) those skills and that knowledge that are key to CNOs being effective. There were responses from 50 countries of the 89 approached; and as to the priorities that the CNOs listed, the following were given, with the most critical issues listed first: a) nursing and midwifery workforce planning; b) policy analysis and development; c) strategic thinking and planning; d) healthcare planning; e) written communication; f) program development and evaluation; g) public oral presentation and personal effectiveness; h) interdisciplinary and cross-sectoral collaboration; i) budget and finance; j) analysis and use of statistical data; k) development of proposals for funding; and l) epidemiology (Salmon, 140).
The authors conclude with the thought that given the "enormously complex" roles of CNOs, and the "significant breadth and depth of knowledge and skills" required to be an effective CNO, it is "alarming that so little research has been carried out" to help the CNOs advance their roles in the sense of helping the health of people "worldwide" (Salmon, 142).
The Literature on Chief Nursing Officers -- What Power do they Exhibit?
Certainly the CNO has a great deal of power in the sense of leadership and oversight in his or her workplace. However, the power of CNOs is sometimes "constrained by board members' limited understanding of quality care and patient safety in general," according to an article in Nursing Economics (Mastal, et al., 2007, p. 324). The CNO has to report to the board of directors, and there is a "huge knowledge gap" between the governing leaders (board members) and those leaders such as CNOs and other nurse managers, Mastal explains (324).
This knowledge gap actually reduces the CNOs ability to operate within the context of patient safety and quality of care, Mastal asserts. In fact there are "differences in perception" among the three groups -- hospital CEOs, board chairs, and CNOs -- as to how to deliver quality care and patient safety. Mastal and colleagues conducted a survey of 73 hospital leaders (CEOs, CNOs, and board chairs) representing 63 hospitals across the United States. The questions focused on: a) important issues facing boards in terms of improving patient safety and quality of care; and b) the actual quality of nursing care that is being provided to patients.
The results show that when asked "what one thing would most positively impact the quality of nursing care," the CNOs listed the following: increasing nurse-to-patient ratios; increasing hours of care; finding sufficient quality staff; reducing turnover and yet hiring new nurses that have fresh ideas; less paperwork; fewer interruptions; increasing nurse satisfaction; and "enhanced communication" (Mastal, 326). Given the situation that CNOs face with boards and with the need for additional resources and more innovative nurses, the power of CNOs can be seen (in general) as limited by circumstances and bureaucracy.