What You Need to Know Right Now to Level Up as a CNO
The Chief Nursing Officer (sometimes known as Chief Nursing Executive) is the top-ranking nursing management professional in any healthcare organization. A July 2017 study of CNOs by AMN Healthcare and The Center for the Advancement of Healthcare Professionals identified about 3,800 CNOs in the United States. The study found these CNOs spent most of their time on culture and operations. Approximately 68 percent of them report directly to the CEO; 91 percent are part of a senior-management team.
The CNO role has evolved from a focus primarily on hospital-based patient care to one much more tied to the organization’s success and results. “When I first graduated from college,” recalls CNO Carol Boston-Fleischhauer in an interview by Thomas Seay, “nurse executives were called ‘nursing directors’ and were typically focused on ensuring that inpatient nursing care was compassionate, safe, and effective – period.” Today, however, Boston-Fleischhauer notes, “organizations recognize that nursing is core to the strategic achievement of outcomes, including clinical, financial, growth/market share, and the like.” To attain those outcomes, she observes that CNOs collaborate directly with the chiefs of medicine, finance, strategy, IT, and quality, “to drive achievement of strategic as well as operational goals.” A respondent to the AMN Healthcare study similarly summarized the role’s evolution “from just staffing the nurse department to being a key player in setting and achieving organizational goals and decision-making for major changes.”
The role’s scope now extends far beyond the healthcare facility. “The CNO role now spans the entire care continuum, from telehealth and community-based care to home health and more, says Lamont M. Yoder, in an interview in Nurse Leader by Heather O’Sullivan. Blogger Pat Magrath calls CNOs consummate problem-solvers, noting that the CNO “balances passion for patient welfare with administrative management.”
Key Competencies for the CNO Role
The CNO role requires at least a Bachelor of Science in Nursing, and often a Master of Science in Nursing (with a suggested concentration in Nursing Administration or Leadership in Health Care Systems, or a dual degree in which the MSN is paired with a Master of Health Administration) or a doctorate in nursing (Doctor of Nursing Practice). Another master’s option is a Master of Business Administration (MBA) or Dual MSN/MBA. Licensure, of course, is a must, with nurses obtaining a state license as a registered nurse by passing the NCLEX-RN from the National Council of State Boards of Nursing.
Additional certifications also are available, including the Nurse Executive certification (NE-BC) through the American Nurses Credentialing Center (ANCC), certifications in Executive Nursing Practice and Management and Leadership (CNML) from the American Organization for Nursing Leadership (AONL), and Certified in Executive Nursing Practice Certification (CENP), also from AONL. The American College of Healthcare Executives (ACHE) also offers a credential, Fellow of the American College of Healthcare Executives.
A nursing career path leading to CNO includes gaining at least five years of increasingly responsible clinical roles that include management.
“As any nurse manager on the executive track will tell you,” exhorts Jackie Larson, senior vice president of a healthcare recruiting firm, “their performance on the job requires skills and aptitude well beyond their training as nurses.” When preparing career-marketing communications to send to employers, those aspiring to the CNO role should emphasize these qualities:
- Passion for performance-driven, high-level leadership
- Patient-care champion, focused on patient-care service and best quality and safety practices
- Strong advocacy abilities to serve as spokesperson for nursing staff
- Keen business sense
- Ability to foster a collaborative and strategic environment
- Expertise in regulatory and compliance approvals and accreditations
- Ability to partner with physicians as well as cultivate relationships across functions and departments
- Change champion
In an article directed at those hiring a Chief Nursing Officer, these competencies and qualities were cited: an eye for detail, current clinical skills, critical-thinking skills, proactive approach to staffing, knowledge of when to lead and when to manage, business acumen, a “data junkie” approach, goal-setting behavior, as well as both knowledge of the big picture and the ability to communicate the bigger picture. The 2017 AMN Healthcare study identified five crucial evolving competencies for nurse leaders: influencing innovation, spanning boundaries, collaboration, expanding the accessibility and use of technology, and courage
Here are a few suggestions for those seeking to break into the CNO role, expand their horizons in an existing CNO role, or even rise beyond the CNO role:
- Boost your expertise on the business side. Experts have identified lack of business acumen as an area for improvement for CNOs. “Even if they have completed BSN or MSN degrees,” Larson notes, “the curriculum they have completed typically does not contain enough, if any, of the business training they will need to perform and advance their careers. The bulk of that learning, at least initially, is done on the job and/or through a mentor.” In her 2015 research Charlene Ingwell-Spolan noted that nurse executives “are unprepared to fully communicate in financial, business terms.” Instead, Ingwell-Spolan points out, “clinical decisions in the health care business are often made by the financial and business executives without full and adequate input from the CNO.”
A list of advice tips for CNOs that Anuja Vaidya collected for Becker’s Hospital Review features these cautionary words from Kathleen Sanford, RN, Chief Nursing Officer of CommonSpirit Health in Chicago: “Looking back over a lengthy career, the one piece of advice I would give my younger self is this: Get as much management and leadership education and knowledge as possible, as early as possible.” Other experts advise reading as many books as possible on executive management and leadership, as well as sharpening strategic skills. “Today’s CNO,” Larson asserts, “must be as comfortable talking about methods to improve productivity and reporting and the strategic importance (or lack thereof) of an IT initiative as they are about patient care initiatives.”
- Advocate for your nursing staff. “Nursing is the largest, most trusted workforce in all of health care and a critical asset to leverage,” points out Boston-Fleischhauer. Serving as the voice for the nursing workforce is seen as a way for nurse leaders to get ahead. “The key to moving forward is having strong nurse leaders who are willing to advocate for nursing in the C-suite,” says Katie Boston-Leary, chief nursing officer at University of Maryland Prince George’s Hospital Center.
- Join or create a peer-support group. That’s the advice of Shane Parker, a nurse who founded a hospital-scheduling software form. The group could be local or could encompass nurse leaders all over if it’s virtual. Parker suggests the group discuss practical and theoretical leadership concepts. Even without a group structure, Parker points out, CNOs can informally seek advice and support from their counterparts by phone or email. “No matter how you construct your support group,” Parker says, “you’ll benefit from interacting regularly with those who have ‘been there, done that.’”
- Gain varied experience by serving as an interim CNO. The 2017 AMN Healthcare study reported that “many organizations turn to interim management as a proven way to bridge leadership transitions;” in fact, 50% percent of nurse executives have utilized interim leadership services. Serving in interim role provides the opportunity for CNOs to gain diverse experience.
CNO Trends to Watch
- Millennials are prevalent in the nursing workforce. About 50 percent of nurses today are of millennial age. One CNO goes so far as to have taken on a millennial nurse mentor so she can understand this demographic. “I think it’s important to stay on top of the issues of the nurses coming in and managing the different generations, [and] to be able to provide opportunities for growth, preceptorship, and communication methods,” states Karen Clements, CNO at New Hampshire-based Dartmouth-Hitchcock.
- Patient and consumer engagement come to the forefront. For the past several years, healthcare systems have been encouraged to engage with patients even when they’re well, Shane Parker observes. Consequently, former CNO Davy Crocket suggests that CNOs “be the Chief Patient Engagement Officer whether you have the title or not. Have a philosophy that the patient and family is always right, even when they are not. You may be the clinical expert, but they know what matters most to them. Engaging patients in their care leads to better outcomes.”
- CNOs are well positioned to be change agents. Crockett also believes CNOs “must become masters of managing organizational change to guide their healthcare system through the constant flux of innovation and disruption.” He advises CNOs to study change-management techniques and be aware that a CNO’s ability to manage change in 2020 and beyond “plays a pivotal role in how well your organization performs in the marketplace.”