This paper investigates the persistent problem of high turnover among Chief Nursing Officers (CNOs) in American hospitals, where most leave their positions within two to five years. Drawing on survey data, peer-reviewed literature, and leadership theory, the paper identifies dual sources of stress — administrative burden and emotional exhaustion — as primary contributors to burnout and early departure. The study proposes a qualitative, interview-based research design targeting current and former CNOs to uncover the environmental, recruitment, and interpersonal factors that drive turnover. Findings are expected to inform hospital leadership on proactive retention strategies, ultimately improving patient care continuity and reducing the significant financial costs associated with replacing senior nursing leaders.
When civilians think of the nursing department in any well-run hospital, they often do not consider all the structure, organization, and guidance required to make this department run as smoothly as it needs to in order to achieve the highest level of patient-centered goals. One position at the top of the nursing department's hierarchy is that of the Chief Nursing Officer, or CNO. The Chief Nursing Officer is the person responsible for overseeing the crux of the entire nursing operation, ensuring that the entire team runs like a well-oiled machine and that all members are accountable for pulling their weight, following policy, and engaging in the most proactive and balanced measures for patient-centered goals (Dickson, 2008). This is without a doubt an extremely demanding job, and it absolutely requires a person who truly enjoys working with patients and other nurses and who thrives on the challenge of offering the highest available level of healthcare.
However, when one looks at the statistics and retention rates of individuals in these positions, the rates are actually quite low: there is a tremendous amount of turnover in this role (Monroe, 2008). This points to a nuanced and serious problem — a high amount of turnover indicates that there is an aspect of the job which is incredibly demanding, so much so that it becomes unmanageable. The evidence indicates that real changes need to be made to nursing departments and the environments they create in order for CNOs to desire to remain in such jobs (Austin, 2010; Figley, 2013; O'Brien, 2010).
The high amount of turnover in this position also suggests that there is something about the structure and environment of the job which is difficult to sustain for many people. These high levels of turnover further suggest that there is an aspect of this work which creates a strong degree of job burnout, which can be debilitating but which can be addressed (Reese, 2008). This paper takes a closer look at the problems presented by the low retention rate of CNOs, why those problems exist, and how they can best be countered and prevented.
Chief Nursing Officers (CNOs) are registered nurses who guide nursing operations in professional healthcare facilities across the United States. The entire nursing department depends on the CNO to demonstrate fairness and leadership in an ever-changing field (Strommer, 2011). One of the most important elements of this role is that CNOs work in conjunction with other chief executive officers to help advance decisions for the healthcare agency at large. This is crucial because CNOs generally have a more direct sense of what is essential for patient care and what the real needs and priorities of patients actually are. These are decisions which can meaningfully improve the level of care that patients receive as well as the overall satisfaction of the staff. Yet CNOs all over the nation are exhibiting a disturbing trend of leaving their current positions as a result of career changes and personal commitments (Salmon, 2002).
Recent relevant research suggests that a serious problem is developing with respect to the retention and turnover of CNOs. The marked lack of longevity in the profession is something that all involved parties must consider and take active steps to address. A study conducted by Jones and colleagues examined CNO turnover using 622 CNOs from across America who participated in an online survey. One of the main findings was that "close to 40% of CNOs reported leaving a position as CNO during their careers. The majority (77%) left voluntarily, with approximately 50% choosing to take another position as CNO and 30% pursuing other opportunities to advance their careers" (Jones et al., 2008). One of the more perplexing aspects of this survey was that many CNOs reported a high level of job satisfaction — just about half of all participants reported being satisfied, and 37% asserted that they were very satisfied with their jobs. Regardless, over half of all CNOs involved in this survey asserted that they had the absolute intention to actively pursue other job opportunities within the next five years (Jones et al., 2008).
The data thus demonstrates that even the bulk of CNOs who were satisfied with their jobs still expressed the need to pursue other careers, pointing to something far more complex and difficult to diagnose about this issue. The problem becomes even more pronounced when one considers that nearly all of the CNOs who participated reported excellent relationships with their staff. "The majority of CNOs reported good or excellent relationships with staff nurses (78%), nurse managers and directors (94%), senior organizational leaders (87%), and CEOs (79%)" (Jones et al., 2008). This clearly demonstrates that more compelling policies need to be put in place to make retention and longevity in this field more organic. There needs to be a greater examination of the leadership process within the CNO work environment, as well as conscious and real adjustments in the process by which CNOs are recruited — efforts that prioritize candidates with an active and passionate desire to promote patient care (Kompier, 1999).
One reason why CNOs are so vulnerable to high turnover is likely the result of dual sources of stress inherent in the position. One source of stress stems from the intensive administrative, bureaucratic, and organizational responsibilities that CNOs carry (Alsop, 2008; Dogbey, 2008; Bern-Klug, 2013). They must oversee the smooth execution of all actions within the nursing department while navigating high-stakes situations where life and death hang in the balance daily. Another source of stress originates from the emotional drain that accompanies this role, even for CNOs who do not have as much direct contact with patients. They remain in an environment that can be quite debilitating, and they directly oversee nurses who are themselves often heavily drained.
"Nurses care for ill, wounded, traumatized, and vulnerable patients in their charge. This exposes them to considerable pain, trauma, and suffering on a routine basis (Coetzee & Klopper, 2010; Hooper, Craig, Janvrin, Wetzel, & Reimels, 2010). While many nurses perceive their work as a calling, few anticipate the emotional implications and sequelae that come from their close interpersonal relationships with patients and families" (Boyle, 2011). Thus, both nurses and CNOs must exhibit high levels of compassion when exposed to distress and suffering, while simultaneously being able to nurture those in their care. If compassion fatigue can negatively influence nurses, it can no doubt have an effect — though a less well-understood one — on CNOs as well. CNOs may also experience the heavy weight of environmental stressors, including expanding workloads and long hours, coupled with the need to respond to complex patient needs. These pressures can result in professionals feeling tired, depressed, angry, ineffective, apathetic, and detached (Boyle, 2011). It is quite possible that CNOs suffer from this type of emotional and psychological damage and may also experience somatic complaints such as headaches and gastrointestinal issues. Both positions require professionals to set aside their own emotional needs in order to meet the constant demands of the job.
The crux of the issue revolves around the consistent trend of CNOs across the nation seeking early departures from their current positions. The general timeframe of departure rests at between two and five years. According to Jones (2008), over 66% of Chief Nursing Officers have been terminated, asked to resign, or voluntarily left the CNO position. Many of these professionals abruptly decide to pursue a career change when leaving this high-stress and demanding role. This trend is deeply troubling, as it suggests an inherent problem with sustaining this position. The pattern indicates that many professionals who work in this position for a few years ultimately want to leave, creating a void and requiring the remaining staff to find replacements — a task that can take at least six months. This slows down the entire nursing department, creating delays in efficiency and an overall decrease in the level of care delivered. More money is ultimately spent in such scenarios, as time is needed both to find and to train a new replacement.
Research needs to uncover whether the low retention rate is primarily a result of job burnout, because the bulk of the data suggests that some level of job burnout is indeed at work. Many of the major factors typically associated with job burnout are common within the field. For example, a common cause of burnout in any profession is lack of control, defined as "an inability to influence decisions that affect your job — such as your schedule, assignments, or workload — [which] could lead to job burnout. So could a lack of the resources you need to do your work" (Mayoclinic, 2014). This is an undeniable aspect of any career in healthcare. Regardless of how well a CNO performs, there will still be adverse outcomes with patients, mortalities, and negative results. Furthermore, many professional healthcare facilities struggle to secure all the funding necessary for their staff to do their jobs effectively, which can create an overwhelming sense of futility throughout the entire nursing team.
Additionally, the position of CNO is a relatively new role within the arena of professional nursing. As a result, there is considerable vagueness about the expectations of the job beyond a general obligation to contribute to the overall excellence of the nursing team. Many CNOs may not be clear on the extent of their authority or what is precisely expected of them, making it difficult to feel comfortable at work (Mayoclinic, 2014). Given that stress levels can become extremely high in professional healthcare environments, it can be far too easy for dysfunctional workplace dynamics to flourish. Bullying, micromanagement, and being undermined by colleagues are negative behaviors that can easily creep in when the workplace becomes high-stress or burdened with too many tragedies (Jutel, 2011).
Additionally, concerted and targeted research needs to be conducted on how many CNOs feel that their personal values are matched by those of their colleagues. Subsequent research also needs to be conducted on the recruitment process and how many people feel that the job is a good fit for their skills and interests as early as the three-month mark. Research also needs to determine how many high-demand extremes are faced by those in the role, since jobs requiring high amounts of activity will inevitably lead to fatigue and burnout (Mayoclinic, 2014). Other factors that can vary on a case-by-case basis include lack of social support, feeling isolated at work or in one's personal life, and an imbalance between work life and personal life — all of which add to a decreased likelihood of having the time, energy, and patience needed to succeed.
As this paper has noted, being a CNO involves an intense level of demand, drain, and stress. Consequently, there is a marked lack of retention of CNOs beyond five years. Concerted research must occur to identify why such a low retention rate exists, what preventative factors need to be put in place, and what issues already exist within the recruiting process that indirectly contribute to the high turnover rate (Stebnicki, 2008; Doornbos, 2005). The specific problem proposed for research is: what factors relating to the recruitment process and the environmental conditions of the CNO position need to be corrected in order to bolster the retention rate? The research method and design need to include a large participant group with survey questions designed to elicit the most qualitative responses possible (Cherniss, 1995). The population for the survey should consist of current and former CNOs.
"Qualitative interview methodology and study goals"
"Literature on nursing leadership and CNO departures"
"Financial and patient care costs of high turnover"
"Leadership theory, assumptions, limitations, and conclusions"
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