healthcare and nursing leadership the CNO

Nurses in executive roles like Chief Nursing Officers (CNOs) build bridges between various members of the healthcare team, between healthcare team members and patients, and also between the legislative environment and organizational practices. In a position of leadership, the CNO also sets the tone for organizational culture. An interview with CNO Oakes reveals some of the most pressing trends and issues impacting the role of CNO and also the healthcare organization as a whole in a dynamic environment. Themes include those related to recruitment and retention of healthcare staff, managing organizational change, collaboration and communication with various members of the healthcare team, workplace incivility, emotional intelligence, team-based communication strategies, regulatory demands, and learning environments.
Recruitment and Retention of Staff
Employee turnover is one of the most pressing issues for nurse leaders and administrators today (Oakes, 2018). Research even shows that turnover rates are high among nurse leaders in executive roles including CNOs themselves (Havens, 2008). Jones (2008) in fact claims that high rates of turnover signals a “crisis brewing,” placing the responsibility upon nurse leaders “to develop strategies and policies aimed at recruiting and retaining” top talent in their organizations (p. 89). Organizational culture and related issues such as workplace environment and managerial practices are generally cited as the primary reasons for high turnover rates or the inability to attract the type of nursing staff the CNO would otherwise prefer (Jones, 2008). Oakes (2018) pointed out that the organization she operates dramatically transformed its organizational structure and culture five years ago, yielding promising results such as a lower rate of turnover among nursing staff, increased pathways to promotions and positions of leadership for minorities, and increased recruitment of nursing staff in key areas of specialization including geriatrics.
Managing Change
The CNO serves in multiple roles at once, sometimes with seemingly competing or conflicting objectives (Oakes, 2018). Managing change within the organization is one of the primary functions of the CNO, who often conducts data-driven needs assessments that drive change or assessments of change strategies and interventions (Stamps, McCormack, Lovetro, et al., 2017). Resistance to change is a serious concern among nurse leaders, including many members of Oakes’s staff (Oakes, 2018). Managing change can involve seemingly simple procedural changes in nursing practice based on emerging evidence-based guidelines, and yet even then, nursing staff may resent the intrusion on their habitual practices and lack the foresight or knowledge to implement the recommended or required changes. Change within the organization can also be drastic, as the structural changes that took place in Oakes’s organization five years ago. Structural changes involved a wholesale reassessment of each department: its function, its role, its relationship with other departments, and its budget. Organizational structure had been hierarchical prior to the change, whereas now the healthcare facility has flattened somewhat while still retaining the benefits of role clarity (Oakes, 2018). Change always needs to be initiated, implemented, and assessed according to organizational mission, vision, and values with patient outcomes, patient satisfaction, safety, and quality of care the primary issues (Stamps McCormack, Lovetro, et al., 2017).
Collaboration and Communication
One of the cornerstones of effective nurse leadership is the ability to foster interprofessional collaboration and communication. Research shows that poor communication between members of the healthcare staff is associated with poor patient outcomes (Foronda, MacWilliams, McArthur, 2016). At the very least, nurse leaders and CNOs should be considered about the ethical ramifications of allowing poor interprofessional collaboration and poor communication to become normative. To promote effective interprofessional collaboration and communicaiton, nurse leaders need to play an active role. Teams need to be formed, engaged, and formally trained to work together as a matter of course (Oakes, 2018). Research substantiates Oakes’s (2018) claims that training programs are important because “standardized tools and simulation are effective in improving interprofessional communication skills,” (Foronda, MacWilliams, McArthur, 2016, p. 36). When the ultimate goal of healthcare shifts to improving patient outcomes, patient communications, and the overall patient experience, nurse leaders can shift their entire approach towards managing staff and motivating nurses and physicians to work together. Oakes (2018) also points out that her goal as CNO is to inculcate a new model of healthcare governance in her organization, under the rubric of shared leadership distributed among various members of the healthcare team. When nurses are empowered to be team leaders more often, patients experience improved communication and transparency and report better impressions of staff and overall quality of care (Oakes, 2018).
Workplace Incivility and Violence
Workplace violence and incivility is a shockingly commonplace problem, with over 75% of all nurses reporting some type of incivility including verbal abuse and physical abuse (Speroni, Fitch, Dawson, et al., 2014). Healthcare environments can cause tremendous stress for patients and their family members, requiring a compassionate and empathetic approach to situations like these (Oakes, 2018). Patients, but also their family members, can perpetrate verbal or physical abuse out of frustration, fear, or anger (Oakes, 2018). However, it is also important to point out that nurses can also contribute to a hostile work environment in many ways: by ignoring abuses perpetrated against colleagues, by belittling colleagues, or by bullying (Speroni, Fitch, Dawson, et al., 2014). Verbal and physical abuse can be curtailed by addressing the root causes of the problem first and then coming up with effective strategies for mitigating the issue (Oakes, 2018).
To address the root cause of the problem, Oakes (2018) claims to have invested heavily in training seminars and other educational programming for staff members. The training addresses every aspect of workplace incivility and violence including the important issue of personal accountability. All nurses need to speak out against any abuses and help to reduce harm, while also addressing fundamental patient needs (Oakes, 2018). To assess the reasons why patients had been abusive, CNOs can do the obvious: come right out and ask patients about their perceptions of care and address any concerns or complaints before they erupt into outbursts of violence (Oakes, 2018).
Emotional Intelligence
Emotional intelligence refers to a cluster of traits and abilities including emotional self-regulation and emotional management, as well as the ability to exhibit and express empathy in ways that fosters strong communications outcomes (Spano-Szekely, Quinn Griffin, Clavelle, et al., 2016). A descriptive exploratory study conducted by Spano-Szekely, Quinn Griffin, Clavelle, et al., 2016) shows that emotional intelligence is positively correlated with transformational leadership styles and behaviors. Specific outcomes of transformational leadership on healthcare teams included the team members exhibiting extra effort in their work, overall improvements in work effectiveness, and job satisfaction (Spano-Szekely, Quinn Griffin, Clavelle, et al., 2016). On the other hand, laissez-faire leadership styles were negatively correlated with these and other outcomes because of the way laissez-faire leadership lacks the connectivity and engagement that epitomize emotional intelligence. Oakes (2018) points out in the interview that emotional intelligence is one of the most important features she looks for on the managerial team because of the pressing need for team members to resolve conflict effectively, and to consider different points of view.
Oakes (2018) also said that nurses at all levels of their profession need to cultivate emotional intelligence actively because it improves patient care and also enhances the workplace environment. When asked about specific ways the CNO can promote emotional intelligence as a desired employee trait, Oakes (2018) said that as of yet her organization did not have any formal policy or strategy. However, considering the wealth of research on the efficacy of emotional intelligence in nursing, Oakes (2018) would consider suggesting a specialized training program for all employees.
Team Communication
The CNO can foster effective team communication using formal strategies like TeamSTEPPS. TeamSTEPPS is described as a “validated multilevel teamwork intervention methodology...with diagnostic capacity to pinpoint opportunities for improving teamwork along specific dimensions,” (Gittell, Beswick, Goldman, et al., 2015, p. 116). Oakes (2018) implements TeamSTEPPS specifically because of its strength in needs assessment.
According to Gittell, Beswick, Goldman, et al., 2015), “the Institute of Medicine argues for a culture of teamwork at multiple levels—across professional and organizational siloes and with patients and their families and communities,” (p. 116). To create a culture of teamwork, the CNO is responsible for selecting and optimizing the team communication strategy that best works in the organization, according to needs assessments. Psychometric evaluations and assessments are a good place to start for conducting a needs assessment, but CNOs should also draw from the Joint Commission recommendations (Oakes, 2018).
Regulatory Demands
Like all members of the senior management team, the CNO is constrained and also guided by the regulatory environment and the shifting demands it places on healthcare operations. The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS) are the two most relevant organizations in healthcare management, impacting everything from cost accounting and billing procedures to how practice is delivered. According to the CMS (2004), a collaboration with the TJC has resulted in a clearer set of regulatory guidelines and demands for standardized healthcare delivery. Oakes (2018) does commend the joint initiatives but also claims that the regulatory demands can be confusing and contradictory, leading to occasional ethical dilemmas.
Learning Environments
One of the roles of the CNO is to ensure that the healthcare organization remains a learning organization, one committed to growth, innovation, opportunity, and above all, patient care. Nurses and nurse leaders can collaborate on the maintenance of a learning environment in their healthcare institutions by implementing new technology and improving the use of evidence-based practice (Cato, Walker, Aders, 2019). A learning environment also means one that actively promotes individual nurse professional and personal development, the promotion of human resources strategies that enable nurses to balance work/life demands, and also allow nurses greater flexibility with regards to their career mapping (Oakes, 2018). However, promoting learning environments also begins at the level of nurse education, where the norms and standards of nurse attitudes and worldviews first become established and entrenched (Cato, Walker, Aders, 2019).



References

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CMS (2004). CMS and JCHAO make it easier for consumers to assess hospital quality. https://www.cms.gov/newsroom/press-releases/cms-and-jcaho-make-it-easier-consumers-assess-hospital-quality
Foronda, C., MacWilliams, B. & McArthur, E. (2016). Interprofessional communication in healthcare: An integrative review. Nurse Education in Practice 19(2016): 36-40.
Gittell, J.H., Beswick, J., Goldmann, J., et al. (2015). Teamwork methods for accountable care: Relational coordination and TeamSTEPPS® Health Care Management Review 40(2): 116-125.
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Jones, C.B. (2008). Chief nursing officer retention and turnover. Journal of Healthcare Management 53(2): 89-106.
Oakes, L. (2018). Personal interview.
Spano-Szekely, L., Quinn Griffin, M.T., Clavelle, J., et al. (2016). Emotional Intelligence and Transformational Leadership in Nurse Managers. The Journal of Nursing Administration 46(2): 101-108.
Speroni, K.G., Fitch, T., Dawson, E., et al. (2014). Incidence and Cost of Nurse Workplace Violence Perpetrated by Hospital Patients or Patient Visitors. Journal of Emergency Nursing 40(3): 218-228.
Stamps, D.C., McCormack, J., Lovetro, C., et al. (2017). The Chief Nursing Officer Council: A Model to Achieve Integrated Professional Practice in Health Care Systems. Nurse Leader 15(5): 335-340.