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A later version of this article appeared in Nurse Leader, Volume 21, Issue 6, December 2023.
As the interim CEO for the University of Iowa Hospitals and Clinics, I was recently asked to speak on a panel of nurse leaders addressing health system CEOs about ongoing disruptions in the nursing workforce. As I spoke, strong non-verbal communications for the audience heightened their intrigue with the panel’s discussion. Descriptions of the now decades-long challenges of the nursing shortage, constraints that prevent nursing schools from quickly escalating the number of nurse graduates to meet the surging demand, increased career opportunities for nurses outside of healthcare even after they are trained, the resulting strategies needed by hospitals to increase recruitment and retention of nurses, and changes in care models were all top-of-mind concerns shared by the CEOs.
A Dearth of Nurse Leaders in C-Suite Roles
Nurse leaders have a wealth of knowledge and experience that positions them well to lead healthcare organizations, both as Chief Nursing Officers (CNO) and Chief Executive Officers (CEOs). Although accurate estimates of the proportion of nurses serving in CEO roles are difficult to obtain, according to a study published in JAMA Network Open that reviewed 3911 healthcare executives, only 17.5% are female.1 According to the US Bureau of Labor Statistics, 87% of the nursing workforce identifies as female.2 These data show that nurses are underrepresented in the CEO role. As nurses are overwhelming female and have first-hand experience in patient care, nurse leaders represent a natural source to help address the gender inequities evident in the female healthcare CEO ranks. In a recent study of Fortune 500 companies, Srivastava, Kashmiri, and Mahajan concluded that “female influence in the top management team is positively associated with (1) customer orientation of the firm and (2) long-term financial performance.”3 In healthcare, customer orientation refers to patient care. Given a keen interest in improving both patient care and financial performance, now is the time for healthcare organizations to recruit CEOs from the ranks of highly qualified nurse leaders.
Nurses Learn from First-hand Patient Care
Indeed, in healthcare, our core business is patient care, and nurses are essential in delivering that care. As nurses rise to leadership positions, those nurse leaders can leverage experience in caring for patients to improve their institution’s processes and resulting operational excellence and learn to apply holistic thinking (systems thinking) skills to better address challenges associated with healthcare today.
Incorporating effective nursing processes into healthcare is fundamental to practice. With experience, nurses learn to develop and apply strong assessment skills across a range of challenging patient situations. Through those assessments, nurses analyze key issues important to the patient and collaborate with multidisciplinary team members to develop a plan of care to help the patient meet appropriate goals. Beyond collaborating to develop a plan, nurses work diligently with the patient and other team members to implement the plan. Throughout the process, nurses collect and document data and then analyze it to assess the effectiveness of the care plan. And finally, nurses adjust patient plans to better achieve established goals, for both the patient and the organization.
Nurses also demonstrate remarkable listening skills with patients, families, and members of the healthcare team. Nurses look at situations holistically and seek to understand patients’ goals, motivations, and barriers to care. Through these experiences, nurses develop as effective communicators, infusing reason into highly emotional situations, and they do so with exceptional compassion. These strengths of nurse leaders are directly transferrable to C-Suite decision-making, where compassion for patients, an ability to place the goals of the organization above one’s self-interests, and an understanding of whether an idea can be implemented are paramount.
Inside Modern C-Suites
Too often, C-Suite leaders become too far removed from the work of front-line caregivers. They may not understand the challenges of delivering patient care, and that concern gets compounded when they don’t spend time with caregivers to hear and consider suggestions. Consequently, some C-Suite decision-making is not well informed about the realities of the workplace. The importance of workplace issues ranging from inefficiencies in documentation to poor communication between members of healthcare teams to staffing and workplace safety challenges influences long-term financial performance and thus warrants inclusion in strategic decisions.
In a recent survey by the American College of Healthcare Executives, Chief Executive Officers ranked workforce challenges as their number one concern and financial challenges as number two.4 Aiken et al. (2023) conducted a cross-sectional multicenter survey study with 21,050 physicians and nurses at 60 nationally distributed US Magnet hospitals. Survey participants reported “high burnout, job dissatisfaction, and intentions to leave their current job.”5 They also reported a lack of confidence in leadership to take action to resolve issues identified by clinicians. Executive leaders with nursing experience can better understand the issues and subsequently work with clinicians to implement changes that will lessen employee dissatisfaction, which improves retention. Moreover, employee satisfaction impacts patient satisfaction—and that ultimately drives revenues.
Nurse Leaders and the Business Side of Healthcare
Healthcare centers on the lives and welfare of people, but it is also a business. While the strengths of nurse leaders are vitally important for leadership roles, nurses can acquire business skills through advanced degrees (e.g., MBA, DNP) or experience to understand the business dynamics of healthcare. Nurse leaders can learn how employee satisfaction, operational excellence, and remarkable patient experiences all contribute to the “bottom line.” Both revenues and costs must be balanced to deliver positive operating margins.
To gain credibility with the more traditional business-focused leaders, nurse leaders need to understand the different perspectives of C-Suite members and communicate using a language understood by each member’s respective discipline. Just as nurses learn to communicate with patients, knowing such perspectives is vital to delivering a message that resonates. The following is a summary of common perceptions of C-Suite members adapted from the American Hospital Association’s C-Suite Cheat Sheet.6
- Chief Executive Officers (CEOs) tend to focus on strategy for the organization and want to be certain that planned initiatives will create a return on investment.
- Chief Nursing Officers (CNOs) focus on patient care operations, workforce issues, and improving quality and safety.
- Chief Financial Officers (CFOs) speak in numbers and are focused on budgets, payer issues, and ensuring a positive bottom line.
- Chief Medical Officers (CMOs) value clinical data and are focused on improving clinical performance.
- Chief Operating Officers (COOs) focus on healthcare operations to meet financial targets and drive service line growth.
As with any team, each member of the C-Suite team brings relevant strengths to the table. More successful leaders connect the strategic vision of the organization and leverage the team’s expertise to drive change and achieve goals. Nurse leaders can develop the requisite skills needed to bring C-Suite teams together in their efforts to improve outcomes. Focusing on the core business of patient care, achieving operational excellence, and supporting caregivers are all vital components to a health system’s success, and that success is a reward our patients deserve.
Steps in Pivoting to the CEO Role
The role of a CEO is broad as it includes all facets of the organization, of which nursing is only a part. CEOs are responsible for setting the strategic direction of the organization and working with leaders to develop and execute plans to meet strategic objectives. The CEO is often a champion of the organization’s culture and ensures financial and operational excellence, growth, and strong community relationships.
A question asked by many nurse leaders today is how do I prepare myself to become a CEO? First, conduct an honest assessment of your skills and experience. Meet with your CEO and express your desire to move into a broader leadership role. Talk with them about their role and the skills most needed to be successful. Then seek learning opportunities to strengthen your knowledge of important areas such as finance, legislative issues in healthcare, and organizational development.
Be open to accepting interim assignments that allow you to develop needed skills. Although new assignments may require you to work outside of your comfort zone, they are very valuable to your growth and demonstrate a willingness to take on new responsibilities. These assignments allow others to see your leadership capabilities through a different lens and may lead to other opportunities in the future.
Consider serving in a COO role. Some organizations now combine CNO and COO roles into one. Many COOs demonstrate the ability to lead the operations of a hospital or health system and in doing so work closely with the CEO. This experience and exposure often lead to promotional opportunities to the CEO role.
Above all, be confident in your ability to lead. As a nurse you possess a critically important skill of caring for and leading people. This skill is essential to lead healthcare today.
References
1. Odei BC, Seldon C, Fernandez M, et al. Representation of Women in the Leadership Structure of the US Health Care System. JAMA Network Open. 2021;4(11): e2136358.
2. US Bureau of Labor Statistics. Accessed July 30, 2023. https://www.bls.gov/cps/cpaat1.1.htm
3. Srivastava C, Kashmiri S, Mahajan V. Customer orientation and financial performance: Women in top management teams matter! Journal of Marketing 2023;87(2):190-209. DOI:10.1177/00222429221120419
4. Survey: Workforce Challenges Cited by CEOs a Top Issue Confronting Hospitals in 2022. Accessed July 30, 2023. https://www.ache.org/about-ache/news-and-awards/news-releases/survey-workforce-challenges-cited-by-ceos-as-top-issue-confronting-hospitals-in-2022
5. Aiken LH, Lasater KB, Sloane DM, Pogue CA, Fitzpatrick KE, et al. Physician and nurse well-being and preferred interventions to address burnout in hospital practice. JAMA Health Forum. 2023;4(7): e231809.doi:10.1001/jamahealthforum.2023.1809
6. C-Suite Cheat Sheet. Accessed July 30, 2023. https://sponsor.aha.org/resources/ceo-cheat-sheet