CNO Retention and Turnover in Hospital Nursing Leadership

Introduction

The vice president of human resources at Munroe Regional Medical Center informed officials at an executive committee meeting that Munroe's turnover rate for registered nurses was 18.8 percent — higher than the 15 percent recorded in 2009 and above the national average, which ranges between 8.5 and 14 percent (Nursing Shortage). Even Florida's state average of 12.3 percent, as declared by the Florida Hospital Association, falls below Munroe's rate. The Tri-Council for Nursing jointly issued a statement on recent registered nurse supply and demand projections in July 2010, cautioning stakeholders about the difficulty of resolving the nursing shortage (Nursing Shortage). The economic downturn had provided a temporary reprieve that, according to many experts, holds no long-term promise. Recent healthcare reforms require more registered nurses than are currently being trained — a rate of preparation that is itself slowing down (Nursing Shortage).

When the public thinks of the nursing department in any well-run hospital, they often overlook all the structure, organization, and guidance required to make that department run smoothly and to achieve the highest level of patient-centered goals (Batcheller, 2010; Figley, 2013). One position at the top of the nursing department hierarchy is that of the Chief Nursing Officer (CNO) (Monroe, 2008). CNOs provide leadership and guidance for the clinical practice of nurses (Figley, 2013) and are considered experts in patient care (Batcheller, 2010). The Chief Nursing Officer is responsible for overseeing the entire nursing operation, ensuring that the team follows policy and pursues the most proactive and balanced measures for patient-centered goals (Dickerson, 2008). CNOs are the leaders in determining priorities related to patient care (Beglinger, 2011). This is an extremely demanding position requiring a person who enjoys working with patients and other nurses and who thrives on the challenge of delivering the highest available level of healthcare. Chief Nursing Officers are also required to work collaboratively with Chief Executive Officers (Strommer, 2011).

When one examines statistics and retention rates for CNOs, however, the picture is troubling: there is a tremendous amount of turnover in this position (Monroe, 2008). High turnover indicates that there is an aspect of the job that is, for many individuals, unmanageable (Salmon, 2002). The evidence suggests that real changes must be made to nursing departments and the environments they create in order for CNOs to desire to remain in such positions (Austin, 2010).

The high level of turnover in this position also indicates that something about the structure and environment of the role is difficult to sustain (Figley, 2013; Wood). Lisa Black and colleagues sought to learn more about U.S. nurses who were active in the industry but working outside of nursing roles. Through conversations with lawmakers, industry leaders, and others about changes in healthcare policy, Black found that decision-makers understood the gravity of the situation but requested statistical backing (Wood). Black believes her updated research and data will provide answers and encourage changes. "Dissatisfaction with the working environment indicates there is space for legislative change," stated Joanne Spetz, Ph.D., associate professor in the Department of Community Health Systems at the University of California School of Nursing and a co-author of the paper (Wood). Spetz believes the paper offers evidence that CNOs can use to persuade budgetary and managerial authorities to improve working conditions — which would support employee retention and reduce recruitment costs. More than 27 percent of respondents cited burnout or a stressful environment, 23.4 percent cited physical demands, and 20 percent cited inadequate staffing as reasons for leaving the nursing workforce (Wood). The authors urge nursing leaders and managers to develop strategies to retain nurses and offer incentives for those who have left to return. "It is only by concentrated efforts to address these loopholes in present healthcare policy that nursing, the healthcare industry, and legislators will have the capacity to meet the nursing needs of the future," the authors concluded (Wood).

Nursing turnover is costly and may have adverse impacts on patient care. Research over a two-year period examined staffing and turnover data on a monthly basis, treating aggregate nursing staff turnover and registered nurse turnover rates as dependent variables in multilevel Poisson regression models (Staggs et al.). Hospital characteristics examined as predictors included Magnet® status, ownership (government or non-government), region (metropolitan, micropolitan, or rural), teaching status, and size. Unit-level variables included total nursing hours per patient day, registered nurse skill mix, nursing staff size, patient population age group, and service line. Government ownership, Magnet® designation, and higher skill mix were all associated with lower turnover. Neonatal units had lower turnover than pediatric units, which in turn had lower turnover than adult units. Psychiatric, critical care, and rehabilitation units had the lowest mean turnover rates, though most differences between service lines were not statistically significant. Notably, registered nurse skill mix proved more important than aggregate staffing level in predicting nursing turnover (Staggs et al.).

Research also indicates that high levels of turnover reflect an aspect of the CNO role that generates significant burnout — a problem that is debilitating but correctable (Reese, 2008). A disturbing trend identified in the literature is that Chief Nursing Officers are resigning from their positions within two to five years of appointment (Courtney, 2002).

A primary lesson from existing research is that a nursing service environment that meets the professional goals of one nurse may not meet those of another (Hunt, 2009). For instance, offering nurses the option to work longer shifts under demanding conditions may be attractive to some while diminishing retention for others. There is no universal ideal job design that will improve retention across all nurses (Hunt, 2009). Healthcare organizations that wish to maximize nurse retention must develop strategies that give nurses the flexibility to structure their roles around their own individual circumstances — including control over schedules, financial incentives that allow income growth, and access to career development opportunities (Hunt, 2009).

The overarching problem is that CNOs are departing their positions within two to five years (Courtney & Yacopetti, 2002). The departure of CNOs causes a detrimental impact on nursing administration and the consistent follow-through of nursing policies and procedures (Dobrovolny, 2008). In recent years, the issue of nursing staff shortages has received considerable attention (Studying Retention and Turnover). Although studies exist on the recruitment and retention of nursing staff, relatively little attention has been given to the relationship between retention, workplace environment, and CNO turnover specifically. Anecdotal evidence suggests a growing increase in CNO dissatisfaction and turnover in recent times, with potential effects on mid-level nurse management, leading nurses, and the general functioning of hospitals (Studying Retention and Turnover).

The cost of CNO turnover equates to a decline in the hierarchical relationships within hospitals and a loss of nursing leadership in management. High healthcare turnover can adversely affect a hospital's ability to address patient needs and deliver quality care. Turnover in nursing services increases both direct and indirect costs (Edmunds, 2010). Direct costs include recruiting, hiring, and training new staff. Indirect costs are reflected in the negative impact turnover has on work unit cohesiveness, job dissatisfaction, burden placed on remaining staff, and below-standard patient care quality (Edmunds, 2010). A study published in the December 12, 2002 issue of the New England Journal of Medicine found that 53 percent of doctors and 65 percent of the general public cited a lack of nurses as a primary reason for medical errors (Nursing Shortage). In addition, approximately 42 percent of the public and more than 33 percent of U.S. physicians reported that they or a family member had experienced a medical error at some point during their care. This survey was conducted by the Harvard School of Public Health and the Henry J. Kaiser Family Foundation (Nursing Shortage).

Chief Nursing Officers are registered nurses who guide nursing operations in professional healthcare facilities throughout the United States and are the leaders in nursing patient care initiatives (Duffield & Roche, 2011). The CNO is depended upon by the entire nursing department 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 — CNOs generally have a strong sense of what is essential for patient care and what the real needs and priorities of patients are (Dreher, 2002). CNOs make higher-level decisions related to patient care policies; without their leadership, policy implementation is delayed (Duffield & Kearin, 2007).

CNOs across the nation are exhibiting a disturbing trend of leaving their positions due to career changes and personal commitments (Salmon, 2002). CNOs must make healthcare decisions and set priorities in their roles related to quality patient care (Dobrovolny & Fuentes, 2008). CNOs are faced with influential factors in the workplace that lead them to seek other career opportunities (Alsop, 2012). Recent research suggests a problem is brewing with regard to CNO retention and turnover. The marked lack of longevity in the profession as a whole is something that all involved parties must actively address (Yacopetti, 2002).

Background of the Problem

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 percent of CNOs reported leaving a position as CNO during their careers. The majority (77%) left voluntarily, with approximately 50 percent choosing to take another position as CNO and 30 percent pursuing other opportunities to advance their careers" (Jones et al., 2008). One of the more striking aspects of this survey was that nearly half of all participants reported dissatisfaction, while only 37 percent asserted that they were very satisfied with their jobs. Regardless, over half of all CNOs involved in the survey stated their intention to actively pursue other job opportunities within the next five years (Jones et al., 2008).

Among the job openings available in San Francisco, registered nursing consistently ranks highest (Yagi). For those pursuing nursing careers there, this is cause for optimism, though local competition in the field makes the employment picture more complex. One Chief Nursing Officer of a major Bay Area health system offered advice to nursing students, encouraging flexibility: "My advice is to be flexible, especially at the onset of your career. Too many students have a fixed role they want to play in the industry. It is not advisable to be rigid about choices — the vocation is evolving in a big way. Such a disposition robs you of opportunities you haven't even heard of. A nursing career has many interesting opportunities in store" (Yagi). There needs to be a conscious effort to observe CNOs who have an active and passionate desire to promote patient care and their relationship with the organization's leadership (Kompier, 1999).

The job demands of CNOs are considerable (Clarkson & Dickson, 2008). CNOs are required to ensure conformity with care, staffing, and clinical standards. They brief senior administration on best practices in nursing and patient care, work with leaders in the social healthcare industry, secure compensation and benefit packages for nurses, and participate in nurse retention, training, and recruitment (RN Management Careers). CNOs may also develop patient care programs, oversee nursing plans, arrange new patient care services, establish nursing policies and procedures, engage in cross-departmental decision-making, train staff for professional development, and represent nursing staff in executive board meetings (RN Management Careers). They frequently oversee multiple departments within a hospital organization and report directly to the CEO. Other CNO responsibilities include:

1. Creating a nursing environment that encourages collaboration
2. Coordinating with physicians to ensure a smooth workflow
3. Ensuring that nursing standards are maintained
4. Maintaining regulatory and accreditation compliance
5. Coordinating with senior administration and medical staff to develop key policies
6. Developing cross-departmental relationships
7. Serving as a representative for nursing staff

One reason CNOs are so susceptible to high turnover and regularly seek new careers after just a few years is possibly the reality that these positions generate stress from multiple directions (Alsop, 2012).

First, CNOs face significant psychological stress that can prompt resignation (Dogeby & Doornbos, 2008). The sources of this stress stem from the many issues CNOs are responsible for managing, including administrative obligations, bureaucratic challenges, and hierarchical tensions (Bern-Klug, 2013). The World Health Organization has recognized stress as a global epidemic, noting that 90 percent of physicians visited reported being affected by stress (Akinboye, Adeyemo, & Akinboye, 2002). The nursing profession is widely recognized as stressful and has negative impacts on the physical and mental well-being of individuals; nursing is physically, emotionally, and mentally challenging (Occupational Stress Management). Studies have found that stress is the most common health issue attributed to long working hours, and its occurrence in nursing environments is increasing (Occupational Stress Management). As defined by Sauter (1999), occupational stress refers to the harmful physical and psychological responses that occur when the requirements of a job do not match the abilities, resources, or needs of the person performing it.

According to healthcare leaders and analysts, the CNO was not always recognized as an integral part of senior administration. Historical accounts indicate that during economically motivated restructuring in the late 1990s, some hospitals implemented an administrative line model of nursing authority that removed the CNO from senior management teams and reduced the influence of the CNO on the organization's strategic direction — a perspective that sometimes persists today (Sanders & Bowcutt, 2004). While more than 80 percent of CFOs present at every executive meeting, fewer than 40 percent of CNOs report to the board with similar frequency. If the financial and clinical sides of hospital operations were separated for comparison purposes, one would expect CNOs to have greater significance at the board level, much as CFOs do (Sanders & Bowcutt, 2004). One challenge is determining what types of data are appropriate for the CNO to present to the board, so as to avoid duplication in reporting. Healthcare facilities should evaluate the types of information reported by the COO and CMO to determine whether some of that information would be more appropriately sourced from the CNO.

The CEO–CNO relationship may have a meaningful emotional impact on the CNO's professional standing. Healthcare leaders advise that CEOs should be encouraged to mentor CNOs and to work in tandem with them to improve their capabilities (Sanders & Bowcutt, 2004). The CEO has access to relevant data that the CNO needs to succeed; conversely, the healthcare facility is disadvantaged when the CNO's knowledge and perspective are not shared with the CEO. Mentoring CNOs can also be a step toward preparing them to meet broader organizational leadership requirements, up to the COO or CEO level (Sanders & Bowcutt, 2004).

Healthcare leaders across facilities should therefore examine the relationships between CNOs and CEOs when investigating reasons for departure (Figley & Fitzpatrick, 2013). Research confirms that stress is a factor that leads CNOs to leave their appointments (Jensen, 2007). Another source of stress stems from the emotional drain inherent in the CNO's environment, even when direct patient contact is limited (Chan, 2007). CNOs operate in an environment that can be quite debilitating, and they directly oversee nurses who are themselves often deeply 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). While many nurses perceive their work as a calling, few anticipate the emotional implications that come from their close interpersonal relationships with patients and families (Boyle, 2011). Both nurses and CNOs must exhibit high levels of compassion in the presence of suffering while simultaneously nurturing those in their care (Clarkson, 2008).

If compassion fatigue can negatively influence nurses, it can certainly have an effect — though a less well-understood one — on CNOs. Nurses who are subjected to intense stress and fatigue may experience a diminished capacity to nurture; CNOs may similarly experience the weight of environmental stressors — "such as expanding workload and long hours, coupled with the need to respond to complex patient needs, including pain, traumatic injury, and emotional distress, resulted in nurses feeling tired, depressed, angry, ineffective, apathetic, and detached" (Boyle, 2011). It is quite possible that CNOs suffer from this type of emotional and mental strain, including somatic complaints, headaches, and gastrointestinal issues. Both positions require professionals to subordinate their own emotional needs to the demands of the role, creating conditions ripe for long-term adverse effects.

Statement of the Problem

The problem under consideration is that CNOs leave their positions prematurely, as documented in existing research. The research methodology encompasses a larger, more comprehensive group of participants, with survey questions designed to elicit qualitative responses aligned with the interview format (Cherniss, 1995). Participants would comprise current and former CNOs, and the general tenure period before resignation falls between two and five years. As noted by Jones (2008), more than two-thirds of Chief Nursing Officers are terminated, required to leave, or voluntarily quit the position.

Despite the attention of specialists and professionals, the issue remains incompletely understood. For instance, it is unclear what specific conditions of the CNO role need to be remedied to improve retention (Stebnicki & Doornbos, 2008). There is also a need for coordinated investigation into how many CNOs feel their values are aligned with those of their colleagues. Further research needs to be directed at the enrollment process and how many individuals feel the position is a strong fit for their abilities and interests within the first three months. Research is also needed to determine the range of activities to which CNOs are exposed — specifically, the factual conditions that generate high levels of stress leading to fatigue and burnout (Mayo Clinic, 2014). Examination is further needed to address why CNOs consistently fail to outlast the two-to-five-year period (Salmon & Rambo, 2002).

Research points to early departure driven by influential factors such as stress (Dogeby, 2008). Many of these professionals abruptly decide to pursue a career change when leaving this high-stress and demanding position, suggesting an inherent issue with sustaining the role. The departure of CNOs causes delays in nursing department efficiency (Wicks, 2005). The pattern indicates that many professionals who work in this position for a few years ultimately decide to leave, creating a void and placing the burden of finding a replacement on remaining staff — a process that can take at least six months (Fitzpatrick, 2012). This slows down the entire nursing department, creating delays in efficiency and an overall decreased level of patient care (Kompier, 1999). More money is spent in these scenarios, as resources must be devoted to both finding and training a new replacement (Wicks, 2005).

Job burnout is a state of physical, psychological, or emotional exhaustion accompanied by doubts about one's competence and job satisfaction (Job Burnout: How to Spot It and Take Action). It is a phenomenon that requires deep insight and thorough study and can have a detrimental effect on well-being. Left unaddressed, job burnout can lead to a host of serious consequences, including:

Excessive pressure; chronic fatigue; sleep disturbances; damage to personal and family relationships; feelings of deep dejection; reliance on alcohol or substance use; heart disease; elevated cholesterol; Type 2 diabetes (particularly in female nurses); stroke; obesity; and diminished immune function.

Many of these factors are common within the CNO role. For example, a frequent contributor to 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 — could lead to job burnout. So could a lack of the resources you need to do your work" (Mayo Clinic, 2014). This is an undeniable reality in healthcare: regardless of how well a CNO performs, there will still be adverse patient outcomes, mortalities, and negative results. Many healthcare facilities also struggle to secure sufficient funding for daily operations, generating an overwhelming sense of futility not just among CNOs but across the entire nursing staff. Poor work-life balance is another cause of burnout; a CNO's role can consume an enormous amount of time and energy, and the loss of social and family engagement accelerates burnout (Job Burnout: How to Spot It and Take Action).

Research also indicates that CNOs choosing different career paths leave healthcare institutions without nursing leadership and nursing policy development for quality patient care. Furthermore, the CNO position itself is relatively new in the arena of professional nursing (Thomas, 2008), which contributes to ambiguity about job expectations and the scope of authority. When stress levels in healthcare become extreme, dysfunctional workplace dynamics — such as bullying, micromanagement, and being undermined by colleagues — can take hold (Jutel, 2011). Issues such as social isolation and work-life imbalance further compound the problem (Stichler, 2006).

As the evidence consistently indicates, being a CNO involves an intense level of demand, emotional drain, and stress (Rambo, 2002), resulting in a marked lack of retention beyond five years. Concerted research is needed to identify precisely why such a low retention rate exists, what preventative factors must be implemented, and what issues already exist within the recruiting process that contribute indirectly to high turnover (Stebnicki, 2008).