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We highlight the design, implementation, benefits, and challenges of an innovative shared nursing leadership model at the chief nursing officer (CNO) level. At St. John's Health, a 48-bed rural hospital in the Mountain West, 3 qualified, experienced clinical nursing directors were recruited to fill the CNO position. During the first 6 months, the CNOs solidified their leadership and communication styles, negotiated salary and benefits, transitioned into strategic thinking, became members of the administrative team, and maintained their specialty clinical directorships. St. John's Health retained strong nursing leadership talent and enhanced staff engagement, resulting in better staff wages and work–life balance, and continues to improve patient experience scores.
Key Points
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A turbulent health care environment is challenging hospital nursing leadership.
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Shared leadership has achieved success at nursing staff and managerial levels.
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Three qualified nurse leaders, at the suggestion of the hospital chief executive officer, designed and implemented a shared leadership model at the chief nursing officer level that retained strong nursing leadership capital and led to satisfaction and pride for all stakeholders.
Persistent and turbulent change in health care is straining the nursing workforce. Economic challenges,
American Association of Colleges of Nursing 2019-2020 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing. Washington, DC: American Association of Colleges of Nursing.
constitute some of the issues contributing to a burdened and disenchanted nursing workforce. Leadership is widely recognized as the path to healthy and productive work cultures to support the health, equity, and well-being of nurses in times of turmoil.
National Academies of Sciences, Engineering, and Medicine. The Future of Nursing 2020-2030:Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press; 2021. Available at: https://nap.nationalacademies.org/read/25982/chapter/1. Accessed May 20, 2022.
Shared leadership as a “relational, collaborative leadership process or phenomenon involving teams or groups that mutually influence one another and collectively share duties and responsibilities otherwise relegated to a single, central leader.”
Shared leadership is not job sharing or shared governance.
The Opportunity
The CNO position opened at a thriving community hospital known for its excellent inpatient experience located in the Mountain West. Over a period of 6 to 11 years prior to that, 3 nurses had risen to clinical leadership positions within their specialties. Each had completed master’s degrees in nursing administration and 1, a master’s in business administration. All 3 expressed a desire to apply for and be appointed to the CNO position. If 1 were chosen, the other 2 would seek a similar position elsewhere, depleting the hospital of valuable leadership capital. A pioneering solution, advocated by the hospital’s chief executive officer (CEO), resulted in the Chief Nursing Officer Shared Leadership (CNOSL) model, or as staff refer to it, the 3CNO model.
Design
As a novel, but permanent, position, the CNOSL model needed design. Four key factors were considered essential: leadership style, communication, salary and benefits, and accountability. Given the 3 clinical directors collectively were employed at the facility for a decade, they knew it and each other well, both personally and professionally.
Leadership Style
The 3 shared an authentic and transparent relational style of leading.
They embraced the values of open communication, collaboration, collegiality, humility, and staff empowerment. Conversely, they rejected one-upmanship and competition, instead sharing a common goal of improving the workplace climate for the purpose of supporting nurses and providing excellent patient care.
All 3 valued flexibility, clinical expertise, administrative capability, and willingness to assist with patient care when needed. They knew all the staff members and sought to be accessible and advocate for them. These concepts align with those documented by Dyess et al
The CNOs’ long-term relationship enabled them to have open, honest, and frank discussions. They share a professional and official CNO office space. When 1 CNO wants vacation, is sick, needs to travel, or has a work interruption, “We just talk.”
The CNOs talk daily, collaborate, and make extensive use of texting. They meet regularly to catch up, troubleshoot issues, set goals and objectives, and monitor projects. Each CNO prides herself on being open, cohesive, and sharing her vulnerability.
Salary and Benefits
Each CNO’s salary and benefit package is identical. The salary was negotiated with the CEO until all 4 parties were satisfied. Expectations were relayed to the human resources department, which found them consistent with the position’s description. Offers of employment were extended and accepted. A level of leadership was eliminated (the single CNO model), and the organization flattened.
Accountability
The CNOs report directly to the CEO, they each maintain their clinical directorship, and are full members of the institution’s administrative/executive team. The CNOs meet every 2 weeks with the CEO. He typically drops in the CNO office and is perceived as extremely accessible.
As displayed in the organizational chart, maintaining their clinical director roles involves each overseeing 2 departments (Figure 1). Nursing staff from the clinical specialty departments report to the clinical director as do unit clerks, certified nursing assistants, and in 1 case, a dietician. Specifically, 1 of the CNOs directs the primary care unit, inpatient rehabilitation facility, and oversees the director of oncology with 90 full-time equivalents (FTE) reporting to her. Another CNO directs home health and hospice and case management, and oversees nutrition services with 15 FTE reporting to her. The third CNO directs critical care and trauma, and oversees the director of obstetrics with 48 FTE reporting to her. Other responsibilities include float pool, the COVID response clinic, and night supervisors. Other clinical directors oversee the medical group clinics, long term care, and surgical services. Because they maintained their clinical director positions and ascended to the CNO position, the 3 CNOs fill 4 FTE. Stated another way, 3 are doing the work of 4 (1 + 1 + 1 = 4).
Figure 1Organizational Chart IP, infection prevention; PCU, primary care unit.
Consistent with the accrediting body, Healthcare Assurance Services by DNV, each CNO is a full member of the administrative team. With the CNOSL model, 3 nurse leaders provide input on direction and decisions. This was an unexpected benefit.
State regulations, the accrediting body, and the Center for Medical Services mandate that 1 CNO be responsible for signatory authorization. Therefore, the official responsibility for this role rotates every 6 months. This mandate is reflected in the organizational chart by referring to the CNO as “acting” (Figure 1).
Implementation
In order to develop their team and introduce their plans throughout the organization, at first, the trio did everything together. As fluidity developed, they divided responsibilities and work schedules in concert with and to support one another. A large “schedule out” calendar indicating who is rotating where and when, and a plan for who covered which task forces and cross-training in roles was implemented.
The trio developed strategies to connect with staff. These strategies include rounding often to be visible and maintaining a supportive atmosphere. They strive to reduce finger-pointing, streamline operations, share problem ownership, and ensure silos are quickly dismantled.
Early in their new role, the trio realized their scope of thinking had to expand. In their director roles, their thinking was operational. They were primarily concerned with day-to-day tasks and operations, and were thinking in the present. In the CNO role, the thinking is strategic, meaning it is focused on the whole of the organization and the future. Since melding the clinical director and CNO role, they have found that both types of thinking are integral and not mutually exclusive. Team strategic thinking occurs regularly among the CNOs, followed by adjustments and decisions. Yet operational thinking is interwoven so the team can move from idea to action.
One CNO summarized her transition between operational and strategic thinking:
I needed to find the balance between supporting the staff and maintaining the best interests of the hospital, recognizing which side of the coin to fight for, and knowing what other concessions can be traded to get what one side needs while offsetting the negative impacts to the other. Always maintain a high level view, even when looking with a microscope. The thinking transition is fluid, there is always the voice of strategy in the background.
To manage the day-to-day tasks, the CNOs start the morning rounding in their own clinical departments. They address problems and touch base with direct staff. They then round the other areas. Tackling e-mails, projects, and meetings, and spotting fires follow. The typical day is sprinkled with meetings.
The CNOs discovered that with unified thinking, they are a powerful and strategic negotiating team. They emphasize consequences and the downstream effects of their requests and decisions. As they problem solve together, they restructure and reprioritize. They have learned to reallocate resources, think creatively, and find new alternatives to old problems.
Challenges
Several challenges were identified in the first months of CNOSL model implementation.
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When big issues arise, small ones suffer. For example, work on the units must be of highest priority, including filling in for staff. A high patient load and staffing shortages result in a focus on bedside tasks. This can distract the CNOs from their focus on strategic priorities.
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Not being treated as a CNO. Some staff tried usurping processes to get immediate needs met. Some perceived that having a trio of CNOs diluted the power of the role.
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Redundancy. Considerable time was spent catching one another up on issues. Yet the time allowed the group to reflect upon solutions and innovative ideas. They have become efficient and refined what issues need to be discussed by all 3.
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Learning to use the administrative assistant (AA). In the clinical director role, few tasks were delegated. The AA is key to reducing redundancy and assuring follow through. They have found that the AA is detailed and flexible, anticipates their needs, brings up future events to plan for, develops required reports and applications, reads and edits documents, fields requests, and is adept and trustworthy at managing their schedules and tasks. They have learned to trust and depend on her. Her role is essential to the success of this model.
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Uncertainty about the transition. Initially doubt was expressed about the model sticking, but at the 6-month check-in, the model is considered stable. Role confidence and a united front communicates that: “we are the leadership,” “staff come through us,” “we are the voice of nurses in the facility.”
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Changing demographics of the staff and the patients.
Retention of existing staff is a high priority. One CNO knew that a nurse was feeling unsupported and undervalued in her role. The trio explored the possibility of finding another role for her in the institution. This approach resulted in maintaining an experienced registered nurse.
Each CNO clocks 50 to 55 hours per week and knows this is not sustainable. They love what they do but won’t sacrifice family and personal time or set a precedent. They intend to hold one another to work boundaries and good health practices.
Outcomes
The model presents “a continuous state of reimagining what is possible.”
All 3 CNOs express pleasure with the role and adequate challenge in the work. The talent all 3 possess has been retained by the organization. The vision, knowledge, and expertise the CNOs bring benefit the administrative team and nursing staff. The CNOs have their feet firmly planted in clinical and administrative groups. Involvement in direct patient care aligns with their personal identity and contributes to satisfaction with the role.
It also enhances immediate feedback to and from administration and clinical constituencies. This model depends on a solid foundation of collegiality among the 3 CNOs, which in this case was growing and developing for almost half a decade. Each CNO has grown professionally and personally in the role. They have learned to problem solve and negotiate as a team, think strategically, and delegate. Each CNO has expressed not feeling overwhelmed.
Accountability for nursing administrative outcomes such as patient satisfaction, cost, quality, effectiveness of care, and organizational performance persists.
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores continue to incrementally improve despite the pandemic, the prohibition of family and visitors during the pandemic, and the new CNOSL model (Figure 2).
Figure 2Hospital Consumer Assessment of Healthcare Providers and Systems Scores/Overall Rating Percentile Rank
The CNOs have instituted monthly town hall meetings for staff. To date, these listening sessions increased engagement between staff and administration. The trio also heard from nurses that they would rather work fewer hours even if it meant a reduced salary. Thirty-hour work weeks for those who want them were negotiated with the support of the administrative team.
Each CNO had a performance evaluation conducted by the CEO. It was perceived as positive and a motivator to continued performance. Each has the opportunity to participate in conferences and continuing education to develop knowledge and skill for the role.
The hospital board of trustees, medical staff, nursing staff, and other clinical directors view the CNOSL as positive. Table 1 contains a compilation of their evaluative comments.
Table 1Anecdotal Comments From Stakeholders About the CNOSL Model
Stakeholder
Comment
The chairwoman of the board of trustees, herself a female executive with 35 years of health care experience
Our CEO promoted 3 well-qualified clinical directors to be joint CNOs with the board’s full support. He took an unusual risk to retain strong talent during a time of disruptive turnover in nursing staff across the nation. To be effective, the 3 CNOs would need to respect each other and to make a significant commitment to clear communication so that the nursing staff, physicians, and all employees would not hear multiple messages. Six months later, their different strengths complement each other well, patient satisfaction scores remain above the 90th percentile, and we have retained all 3 individuals. The positive was being creative and doing something different in retaining talent by eliminating a level of leadership and using the savings to give significant raises and provide opportunities for growth.
Physician
The 3CNO model, which we now fondly call the distributed nursing leadership model, has worked seamlessly. Mary, Naomi, and Jen are accessible and work so well together that the medical staff feels they can approach any one of them and receive the same response and outcome. Further, retaining the ready availability of the directors’ operational and clinical knowledge and expertise is highly valued.
The primary care unit charge nurse, baccalaureate-prepared and certified RN
The 3CNO model has been an asset to our hospital. Having the 3 CNOs also as directors of clinical areas allows the CNOs to have a presence with the direct nursing staff and know the happenings of clinical nursing areas. There is a face to the CNOs that most hospitals do not feel or see. I do fear that having the 3 CNOs also in director roles may lead to faster burnout with multiple stressful roles. The CNOs need a good support system in the manager or charge nurse role to help in the relief of some of these stressors
Director of wellness, baccalaureate-prepared, board certified in gerontology RN
The 3CNO model has been a very positive transition and model. Each one of the CNOs brings their own gifts and skills to the organization and in this current crazy environment this model adds strength and energy to the constantly changing and otherwise depleting system. They are all approachable. They not only support their staff but also one another and as a result are examples of cohesive leadership. This model exemplifies positive teamwork and limits the perception that departments are siloed within the organization. Every department in the system is represented fairly. All have excellent communication with one another and with the staff as a whole. As the director of the wellness department, I hear many comments and grievances from the staff on occasion related to a multitude of circumstances and situations. I have only heard positive and supportive comments from our employees related to our 3CNO model. Employees feel that they can approach the CNO they feel most connected to personally, professionally, and or departmentally, which limits barriers of communication and enhances the experience of being heard and supported.
Clinical director of obstetrics, a travel nurse
I have never seen an organization gather data, make decisions, and fulfill requests so quickly. I credit the 3CNO model.
Overall, the impression of institution stakeholders is that the organization has been flattened, giving the bedside nurses access and availability to the CNOs. Each clinical nurse now has the ear of a CNO who is participating in the decisions of the administrative team.
Future Considerations
Beyond staffing and budgetary concerns, at least 6 issues are considered immediate goals for the coming months.
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Renewal of the hospital’s codified nurse practice council. A victim of the pandemic, it’s deemed important to have input from organized nursing.
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Succession planning for themselves and other clinical directors. How will the trio continue to evolve? How can the departments not overseen by the CNOs as clinical directors be better represented? Is this model sustainable?
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Could a 1-to-1.5 FTE clinical manager position support the director roles, as suggested in one of the staff comments?
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How should a nurse residency program and preceptorships that are being considered, a challenge for an organization of this size, be addressed?
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If leadership at the CEO level changes, what implications will this have for the CNOSL model?
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Outcomes of the model, other than the HCAHPS scores, are anecdotal. A systematic outcome evaluation, including costs, needs conducting.
Conclusion
Together the CNOSL incumbents have 10 years of nursing leadership experience at this organization and different, but complementary, skill sets and strengths. All were bedside nurses and aspired to be chief executives; each are analytical professionals, exemplary at taking and providing advice, troubleshooting, and comfortable at coming to nonjudgmental collaboration. This model is not ideal for all organizations. It works because of an extensive foundation of trusting relationships among the incumbents and strong administrative support. Importantly, it accomplishes the goals of keeping nursing leadership capital and demonstrating nursing leadership from the bedside to the boardroom.
References
Gallagher R.M.
Rowell P.A.
Claiming the future of nursing through nursing-sensitive quality indicators.
National Academies of Sciences, Engineering, and Medicine. The Future of Nursing 2020-2030:Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press; 2021. Available at: https://nap.nationalacademies.org/read/25982/chapter/1. Accessed May 20, 2022.
Susan K. Riesch, PhD, RN, FAAN, is Professor Emerita at the University of Wisconsin-Madison School of Nursing in Madison, Wisconsin. She can be reached at [email protected] Jennifer Chiappa, MSN, RN, is chief nursing officer, director primary care unit, and director inpatient rehabilitation facility, Naomi Floyd, MSN, RN, is chief nursing officer, director home health, and director case management, and Mary Ponce, MSN, MBA, RN, is chief nursing officer and director critical care services/trauma (emergency department) at St. John's Health in Jackson, Wyoming.
Article info
Publication history
Published online: October 06, 2022
Accepted:
September 6,
2022
Received:
August 11,
2022
Footnotes
Note: The authors are indebted to Audra Nielsen, administrative assistant, for her grasp of the institution and its leadership, her skill at reading and editing, and her overall support, quickness, and kindness in the development of this paper. We also thank Barbara Pinekenstein, PhD, RN, FAAN, Richard E. Sinaiko Professor in Health Care Leadership, at the University of Wisconsin-Madison for her extremely thoughtful comments on previous drafts of the manuscript. Her knowledge, competence, and enthusiasm for the field of nursing leadership is enormous and much appreciated. The authors have reported that they have no conflicts of interest to disclose relevant to the contents of this paper.
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