Havens, Donna Sullivan PhD, RN, FAAN; Thompson, Pamela A. MS, RN, FAAN; Jones, Cheryl B. PhD, RN, FAAN
In hospitals, the chief nursing officer (CNO) advocates for patients and nurses at senior leadership levels and is responsible for ensuring the capability and capacity of the nursing department.1-7 Chief nursing officers "shape the environment in which nurses practice, students learn and consumers receive health care with the goal of inspiring those around them to reach for excellence."8 The CNO drives initiatives to improve patient safety and increase the quality of care while managing the complexities of the nursing workforce and controlling costs.9 Thus, the CNO is the primary architect of the nursing practice and patient care environments, which have been linked with nurse retention and safe, high-quality patient care.10
Because of concerns about growing turbulence in this vital role, "a crisis brewing,"11-13 and the paucity of research conducted over the past decade about CNO turnover, the American Organization of Nurse Executives' (AONE) Institute for Patient Care Research and Education conducted a multiphase study of CNO turnover and retention in US hospitals. The purpose of the study was to generate information to inform the development of strategies to improve CNO recruitment and retention. The study consisted of 3 phases: (1) an anonymous online survey completed by current and past CNOs,11 (2) telephone interviews with CNOs and healthcare executive recruiters, and (3) an anonymous online survey of nurse managers and staff nurses in hospitals to gain their perceptions of the impact of CNO turnover on their work and the delivery of patient care.
The take-home message from the first phase of study was that approximately 62% of the respondents anticipated making a job change in less than 5 years, although only slightly more than a quarter reported that they would leave for retirement.11 In this article, we complement these findings by presenting the results of our second phase of study, which examined CNO turnover as described in interviews with current and former CNOs and healthcare executive recruiters.
A qualitative descriptive design was used in this phase of the study. Current and past CNOs and healthcare executive recruiters employed in search firms known to recruit for vacant CNO positions in hospitals were interviewed by one of the study investigators.
All of the CNOs who participated in the phase 1 survey were provided with information at the end of the survey inviting them to contact a study investigator if they wished to volunteer to participate in the phase 2 interviews. In addition, all US hospital and health system CNOs, both AONE members and nonmembers, were invited by e-mail to participate in the interviews (including those who did and did not participate in the online survey). Healthcare executive recruiters employed in executive search firms known to recruit for CNO employment were invited by e-mail to participate because we believed that they would contribute a unique perspective on what is happening in regard to CNO searches, the skills sought or required for CNO positions, and the CNO candidate pool.
Individuals interested in participating in the interviews were contacted by one of the study investigators. Because participants were located across the United States, all 35- to 40-minute interviews were conducted by telephone at the participant's convenience. Interviewees participated from a location of their choice (eg, home, work, or from another remote site). In all, 26 interviews were conducted with current and past CNOs and healthcare executive recruiters. Among the CNO participants, 10 had been terminated or asked to resign-that is, they changed jobs involuntarily-at least once during their CNO career, 4 had voluntarily left a CNO position at least one time during their careers, and 7 had never left a CNO role. Five healthcare executive recruiters were interviewed.
An interview guide was developed by the study team from the literature on CNO turnover, nursing leadership, and management/leadership transitions. The study was approved by the Institutional Review Board of the University of North Carolina at Chapel Hill. Before the interview, an informed consent was read to each interviewee, and consent to participate was obtained by the team member conducting the interviews.
Field notes were transcribed verbatim and reviewed by the research team member conducting the interviews to ensure recording accuracy and to fill in gaps. Interview transcripts were typed then submitted to the other authors for identification of themes and associations. The data were summarized using the qualitative description technique outlined by Sandelowski.14
Data were aggregated and are reported here by the 4 groups who participated in the interviews: CNOs who had involuntarily departed, CNOs who left their jobs on their own volition, CNOs who had never left their jobs, and healthcare executive recruiters. For the most part, similar themes emerged within groups and themes differed between the groups. Because the primary purpose of the study was to develop knowledge about CNO turnover, we focused on the stories told by the CNOs who had been terminated, had been asked to resign, or had voluntarily resigned and from healthcare executive recruiting professionals. Data from CNOs who had never left their jobs were used to add context to the findings.
CNOs Who Involuntarily or Voluntarily Left Their Jobs
In total, 14 of the 21 CNO informants reported voluntarily or involuntarily leaving the CNO role at least once in their career. Ten reported that they had been terminated or asked to resign from their CNO role involuntarily. Four informants had voluntarily left their positions during their CNO careers.
The 10 informants who had experienced involuntary turnover had served as CNO at their hospital between 1.5 years and 22 years when they departed. Of these 10 informants, 7 were employed in a CNO position at the time of the interview. The 3 who were not employed as CNOs at the time of the interviews were working as consultants. Two of these 3 reported that they might consider returning to the CNO role at some point in the future. One reported that she "would seek CNO employment under the right circumstances." The second said, "I have things I want to do before I go back to it [the CNO role]," whereas the third participant said, "I would never go back and be a CNO." All 10 informants who involuntarily departed told poignant stories about their personal experiences and feelings.
Four informants had never been terminated or asked to resign. However, at some time, all 4 had changed jobs voluntarily. All 4 were employed as CNOs at the time of the interviews, and they had been in this role at their current organization between 1 and 4 years. This group of informants told stories that were quite different in tone from the stories told by those who had experienced involuntary turnover.
Pushes: Factors That Promoted Leaving
Informants who had involuntarily departed reported 4 central themes that led to their turnover (Figure 1).
1. Hospital financial concerns: "hospital bought out," "downsized the number of vice presidents [VPs] from 11 to 4"-the CNO was a vice president, and "[t]hey were eliminating positions because they needed to save money and didn't think they needed this [CNO] position."
2. Conflict between the CNO and chief executive officer (CEO) or other members of the senior leadership team: "isn't working out"; "the CEO didn't trust me"; "wanted nursing to go in a different direction"; one CNO was told, "You are going to leave now… pack up your things and go with security"; and conflict about "ethical issues such as billing practices" and the "process for reporting medication diversion."
3. The appointment of a new CEO: "[a]t our first meeting he said, 'You need to be a CEO at another hospital; this hospital isn't big enough for both of us'"; another CEO told the CNO, "[I] want a CNO who is here [more often] and not involved nationally"; one CNO said that the new CEO "wanted new leadership in all positions."
4. Others' concerns about CNO financial management capabilities: "[t]old that my financial management skills 'were not there'" and "[t]old that I was not going to be able to meet financial goals… even though I had been a good financial steward."
Those who voluntarily made the decision to leave a CNO position in the past reported reasons that included "moving on," hospital purchase, and ethical issues (though it was their decision to leave). For example, one CNO reported that her voluntary departure was in response to an ethical issue surrounding the hospital's effort to defeat a union challenge. She reported that she was brought in to challenge the union campaign and she had "put in enough good things to defeat the union push." She reported that "[a] year later the CEO wanted us to take away what we had given them [the nurses]." The CEO informed her that "[w]e only did [what we had to] to keep the union out." The implication was that the CEO had deceived both the CNO and the hospital staff to withstand the union's challenge for his/her own benefit rather than acting out of concerns for improving nurses' work environment and their welfare.
Signs Predicting What Was to Come
Four main themes emerged from the data forecasting "what was to come" for those who experienced involuntary turnover as follows (Figure 2):
1. Deterioration of the CEO-CNO relationship: "lack of recognition for my role"; "disagreed with me publicly"; "not using me as an advisor"; "never asked about nursing… started to micromanage"; "[I was] not able to attend board meetings"; "[i]t was clear that my work style and values weren't consistent with his. I was already searching for a position because I saw it coming."
2. Ethical conflicts/differences: "there were things that were being covered up-I hoped that we could move forward appropriately and we didn't."
3. Hospital fiscal health: "new mantra became… money is king… I guess that should have been my clue"; "I had seen financial numbers and knew that they were looking for ways to save money."
4. "Blindsided": "no signs… right out of the blue"; "came up at my first meeting with him [new CEO]"; "I had outstanding performance appraisals"; "[i]f there were signs, I missed them"; and "became an issue all of a sudden."
The Feelings Experienced During Turnover
Informants who had experienced involuntary turnover told stories that brought intense emotions to light, including surprise, shock, betrayal, anger, hurt, uncertainty, questions about their own values and self-esteem, and ethical/legal dilemmas. Informants shared the following feelings about the experience: "[It was] the most painful situation in my career," "[I felt] shame for being asked to resign," [I felt] "concern about [my] future financial status and employment opportunities," "[I felt that there was] no appreciation for what I had done," "I was disgusted with leadership," "There was no closure with staff; gone that afternoon," and "[It] lowers your self confidence." Several informants also reported being "heartbroken," "[w]orried that those left behind weren't safe," "[I felt] terribly rejected," and "[i]t was devastating to be asked to leave like that."
In contrast, 3 themes emerged from interviews with those who had voluntarily left. The first was emotional attachment to the workplace-[It was] "difficult to leave." The sense that it was difficult to leave was related to feeling "a sense of loss from [leaving] a work environment that was so inclusive." One CNO reported, "I had some grief because I loved the people I worked with." The second theme was affirmation/pride-"I had accomplished a lot and left it [the hospital] better than I found it." One informant said, "I was proud of what I did-[it] showed integrity." Finally, the third theme was related to work-life balance. Informants reported that they needed time to refresh-[I] "Needed time away-traveled for a year," "[There is] more to life than work," and "I could do what I wanted."
Supports to Ease the Transition
Among informants who experienced involuntary departures, several mentioned that family and friends were "there" for them (eg, "You need family and friends at that time" and "It would be hard to have relationships with anyone at the facility"). Others identified professional networks as key supports-"[w]ent to the local ONE and talked with colleagues; they were wonderful, open and receptive. No one ever said 'I can't help you'"; "AONE"; "tips from colleagues." Community networks were also identified as supportive during this period-"[a] CNO from a competing hospital in the community called and said, 'You have been a significant contributor to the community.'" Another informant reported that the state hospital association "[c]alled and put me on committees… this was helpful in building a network and for developing new opportunities."
Other informants, however, reported that they had no supports-[I was] "alone." Whereas some informants reported that their former hospital team (leaders, staff, and the CEO) were helpful, others reported that "colleagues were worried [about their own fate] and not there [for me]." One informant reported that "[t]he [other] vice presidents were afraid (would they be next?)" and "it was like I died and was a ghost." Another said that "[t]he people you thought were friends were not there for you and those you least expected came to help." Finally, some informants said that support was gained from severance packages, outplacement services, professional executive healthcare recruiters (often ones with whom they had worked in the past), attorneys, and colleagues in schools of nursing (Figure 3).
Supports That Would Have Been Helpful to Ease the Transition
When informants who had involuntarily left their jobs were asked to identify the types of support that would have been helpful to them at the time; 5key themes emerged (Figure 4). There was a strong sense that talking with "those who understand" would have been helpful-"CNOs who had gone through it," "a support group," "a support group that would identify lawyers and recruiters," "support of a professional organization." Counseling and coaching were identified as other forms of support that would have been helpful-"short term counseling to get beyond the sense of it being personal," "coaching about how to tell others you were fired," and "counselors who could help you to face the grieving process." Legal information and alternatives were another form of support that would have been helpful-"a list of legal options"; "advice about how to get the best severance package"; "in the future, I would arrange a severance package [up front]." Several pointed to the help they received from talking with recruiters and outplacement specialists.
Those CNO informants who had voluntarily made the decision to leave the position reported many of the same themes when asked about the support available to them (CEO, colleagues, family, networks, human resource [HR] management, outplacement services, and severance packages). What differed was that they did not report colleagues appearing to be afraid to associate with them nor did they report feeling as if they were going it alone.
Lessons Learned: Things CNOs Who Involuntarily Departed Are Doing Differently in Their Current CNO Role
When CNOs who had experienced involuntary departure were asked to share what they now do differently because of their experience, 3 themes emerged: "caution," "trying harder," and "a new philosophy." Informants said that they would be more careful in the future-"Once you go through that, you aren't as trusting"; "if it is your job or theirs, it will be their job that they will protect"; "How I approached the job search changed; I asked questions about physician relationships, how various situations were handled, and how they would deal with ethical issues." Trying harder was reflected in efforts to incorporate lessons learned from the past in their current CNO role (eg, "I am trying harder than ever to keep my CEO and administrative team informed… striving to assure that we have good communication.") In regard to a "new philosophy," respondents said, "I have a [new] philosophy that leaving a job isn't to be feared any longer; I believe I will land in a better place"; "[I am] realistic that no job is perfect-when the challenge is gone, [it is] time to move on"; "Don't let them not include you!! I was advised [about this] by another senior person; I moved my office next to the CEO"; "For my own personal security I have more money set aside; I have 6 months worth of funds"; and finally, "I have more respect for my own integrity" (Figure 5).
Pulls: Factors That Would Keep You in a CNO Role
Chief nursing officers who left involuntarily reported 4 "pull factors" addressing 'fit' with the organization that would keep them in a CNO role (Figure 6). The first was compatibility/fun-"It's [got to be] interesting and challenging"; "a place that is compatible with your value system"; "[You] need to like it; if you don't like it you won't last long." The second was "making a difference"-"I am an advocate for nurses at the bedside," "ability to influence how nursing is practiced and perceived in the hospital and the community," "I want the power to make a difference," "I don't think I would be satisfied with anything but the CNO position. Job satisfaction comes from making a difference and the CNO does that." An environment that values nursing was a third pull-"to have nursing valued and part of senior leadership," "a collaborative and participative environment," and "knowing that the organization was supportive of nursing." The fourth pull was ethical leadership-"I will need good ethical leadership and then I will go back as a CNO or CEO."
Important Insights From CNOs Who Never Turned Over
Seven CNO informants reported that they had never left a CNO position; they had served in the role between 1.5 years and 18 years at the time of the interview. A few questions were targeted specifically at these CNOs who had never changed jobs, such as what kept them in the CNO position? Four key aspects of the role that influenced staying were reported.
1. Ability to lead positive change and make a difference: "lots of changes and I am part of those changes," "ability to influence change that impacts patients and the overall wellness of the community," "ability to work with a great team (nursing staff, medical staff, patients) to make a difference," "ability to do what needs to be done."
2. Passion for the CNO role: "feels good"; "I love it… it is a wonderful role"; "lots of opportunities"; "meets personal needs. I am professionally challenged… is stimulating"; "ability to be creative and innovative when health care is falling apart."
3. Mentoring and enhancing nursing practice: "watching nurses flourish"; "ability to advocate for nurses"; "mentoring nurses into leadership roles… I worked my way up and can help others to see that it can be done."
4. Good relationships with the senior leadership team: "[m]y CEO is very supportive of nursing and me," "good relationship with CEO," "executive management team and the voice I have [on the team]," "[the CEO is] fabulous-wise, wonderful," "supportive-includes me in all thinking sessions," and "respects my knowledge."
We also asked this group to tell us about supports that are important for them in their CNO role. We anticipated that these responses might provide important insights about supports that could be instrumental in keeping CNOs from turning over. Four general themes emerged.
1. Professional colleagues: "more experienced CNOs are around to help me," "finding a peer group," "the head of the college of nursing," and "good collegial relationships."
2. Leadership team: "support of CEO, COO, CFO", "lateral support at peer level in finance, IT," and "support to understand financial aspects of the CNO role."
3. Professional organizations: "the American College of Healthcare Executives and AONE" and "AONE, American Nurses Association… before I interviewed for the job I interviewed these associations."
4. Support for national professional involvement: "ability to belong to professional associations with [hospital] financial backing" and "support for conferences and workshops."
How CNOs Perceive That CNO Turnover Affects Staff and Patient Care
All 21 CNO participants were asked to share their perceptions about how CNO turnover affects staff and patient care. The themes that came to light in response were quite similar across the groups (Figure 7): destabilizing, trust and security, a culture of fear, the quality of care, public perceptions, and program inertia. Across the groups, informants identified destabilization and negative impacts on the quality of patient care ("systems start to fall apart and care erodes"). Those who had been terminated or asked to resign said that CNO turnover "creates staff unrest," "a lack of [leadership] consistency and approach," and "[e]veryone is antsy… here is another one [leaving]." One informant pointed to the culture of fear that evolved-"frightening… the unknown"; "if it happened to her, it can happen to me"; "[w]here is the organization going?" "what about the practice of nursing?" Others said that CNO turnover could lead to program inertia ("programs don't get off the ground" and "ideas change each time you have turnover"). One often reported example of a strategic activity perceived as suffering because of turnover was the American Nurses Credentialing Center Magnet Recognition process. Finally, public perceptions were reported as a concern, with the potential for "staff talking to patients about the uproar" and "inappropriate things said to the public." One informant who voluntarily resigned reported that the impact on staff and patient care "depends on CNO popularity."
Insights From Healthcare Executive Recruiters
Reasons for CNO Turnover
The healthcare executive recruiters identified 5 key reasons for CNO turnover: (1) career move-"going to a new position as a desired move," "growth potential-smaller to larger hospital," and "seeking a promotion"; (2) senior leadership change ("no common vision with the CEO or the organization"); (3) cannot do their job-"energy drained because there was no infrastructure to support them," "can't accomplish what they came for," "not demonstrating competencies"; (4) reporting relationships-"don't want to report to COO anymore… want to report to the CEO"; and (5) personal reasons, such as spousal transfer, the need to relocate, care of aging parents, or retirement (Figure 8).
New Trends Influencing CNO Job Change Behaviors
Executive recruiters described 3 new trends that are influencing CNO turnover (Figure 9): (1) the increasing complexity of the CNO role-"more pressure on CNOs as the nurse shortage increases" and "the role is just harder"; (2) financial management issues-"money is tighter… CNOs find that they have to fight more to validate the budget for nursing than before," [there is] "an increasing demand for skill sets that are finance [related]," and "failing to understand financial performance"; and (3) senior leadership transitions-"higher percentage are leaving due to a new CEO/COO."
The Skills Employers Are Requesting
Executive recruiters were asked to identify key skills that employers request when searching for CNO candidates. The desired educational/work experience for the CNO role was reported as "MS [master's degree] and 10 years of experience in management," "diversity management," and "prior CNO experience." One recruiter reported that the "requirements are so specific that they eliminate a lot of people." Specific financial and business skills are sought: [how to] "calculate productivity," "stronger focus on the business side," and [how to] "deliver care more efficiently." Candidates are desired who have the ability to develop a strong nursing department ("understanding of nursing and the whole organization," "visible leadership-be connected to bedside nurses and value their service," and the "ability to recruit and retain nurses"). Those who bring specialized experience are sought (eg, "Magnet recognition experience" and experience with roles that deal with quality, safety, and satisfaction). Personal attributes such as "a sense of humor," "passion for advancing nursing," and "strong communication skills" are highly desired. Finally, the ability to collaborate with physicians is also highly desired by employers-[the CNO] "must relate well with MDs."
Critical CNO Recruitment and Retention Issues
Executive recruiters were asked to identify critical CNO recruitment and retention issues. Five factors were identified as key to recruitment (Figure 10): (1) CNOs wish to be a partner in leadership, (2) the candidate must be a good match with the organization, (3) commitment to quality, (4) the compensation package, and (5) HR management involvement in the recruitment process. Human resource involvement was identified as a source of frustration for executive recruiters during the recruitment process because (in some cases) they questioned the ability of the HR staff to appropriately screen or evaluate such high-level candidates. However, HR involvement was described as a frequent part of the process (eg, "We have had the HR people take the cheaper candidate rather than the right candidate"). Five critical CNO retention issues were also identified by these informants: (1) relationships with senior leadership team, (2) the compensation package, (3) the authority to do the (CNO) job, (4) work/life balance, and (5) the location of the institution.
At the end of each interview, all informants were asked if there was anything else that they wished to communicate. Several CNOs shared thoughts in response to this final question (Figure 11). One theme was that the CNO "gets left out of the senior leadership team and that is a disadvantage." "You need to be tied in with the CFO and the CEO. It is hard if you are not seen as part of the senior team." One informant recommended that "the CNO needs to insert herself or himself and not hang back… invite yourself." Another recommended that "CNOs need a better understanding of business and running a hospital." Still another CNO recommended that CEOs and CNOs "need a place for mutual exploration of the CEO and CNO roles and clinical needs. Maybe we could start with folks now in the CEO and CFO roles. We are all reading the journals, but I want to see more about relationships." Another informant said, "[a] lot of times I feel that many CNOs didn't have supportive CNOs [as mentors]. I like to mentor as many as possible." Finally, one informant advised, "[t]he power is from within… we don't always look to ourselves. We look for permission [from others] too often. My failures have been when I didn't change and take risks. I am now braver in giving feedback… able to state the truth. I live my values and that makes me a better leader."
Several executive recruiters also shared final thoughts. One said the current environment was a "time of great opportunity for nursing" because of concerns about quality and safety. This informant suggested that the Magnet recognition program feeds into this and the CNO role is vital to success in the Magnet process. Succession planning was also considered imperative-"have to create the next generation [of CNOs]." Another confided that in her opinion, "[t]he talent pool is lean… the truly gifted are not there," suggesting that current CNOs need to recruit and groom talent for roles as future CNOs. Finally, concerns were expressed about educating and mentoring the next generation of aspirants for the CNO role so that they can "talk the financial language to compete on the same level" as other members of the senior leadership team.
We acknowledge that this study would have benefited from a larger group of informants. However, because of the sensitive nature of involuntary CNO turnover and the stigma perceived by many who experience it, recruiting participants into a study of this kind was a challenge. Nonetheless, this study highlights many important findings and also provides new information on CNO turnover and provides a foundation to develop programs and initiatives that focus on educational and experiential preparation for future CNOs, professional development and mentoring of current CNOs, and supports needed by CNOs who are forced out of those roles. For instance, the findings reinforce the need for advanced financial skills, productive relationships with other senior executives and physicians, and the need for a supportive professional colleague network. They also emphasize the importance of succession planning, an area in dire need of attention as we plan for the CNO role of the future.
The American Organization of Nurse Executives is taking action to address the important themes that emerged from this research. First, the study findings have been widely disseminated to inform CNOs and those who work closely with CNOs, as well as those who are educating future CNOs. Second, AONE has developed initiatives and taken steps to specifically address study findings. These will be highlighted in this section.
Throughout the interviews, across all groups, informants identified "good relationships with the CEO and executive leadership team" as crucial for recruitment, retention, and success in the CNO role. However, maintaining excellent CEO/CNO relationships is becoming increasingly complicated as turbulence in the CEO role increases. Findings from a recent study of CEO turnover in 6 states pointed to short CEO tenures (including "involuntary departure"), with 1 in 6 CEOs leaving their jobs every year and with some hospitals reporting 3 or more CEO turnovers in 5 years.15 Such executive leadership instability coupled with the "crisis brewing" in CNO turnover present challenges when it comes to building and sustaining executive leadership team relationships. This turbulence highlights the growing need for all senior executives to understand complex adaptive systems and to develop skills for leading and managing in the complex work environment resulting from rapid and constant change.
Consistent with the findings of a 2005 survey of CNOs conducted by the Voluntary Hospitals of America and Witt/Kieffer,13 all groups interviewed identified the need to "build CNO skills for success," including building and supporting financial management acumen. Recommendations included educating, preparing, and mentoring the "next generation of CNOs" to be well equipped to "talk the financial language to compete on the same level" as other senior hospital leaders. Because the relationship between the nurse executive and the chief financial officer is critical, AONE and the Healthcare Financial Management Association (HFMA) are collaborating on several initiatives to enhance the manner in which these 2 executives work together. One key initiative has been the partnership to copublish The Business of Caring, a newsletter that focuses on financial issues in patient care. Each issue contains in-depth articles written from the combined focus of nursing and finance that highlight the joint perspectives that can improve the understanding and actions taken by the CNO and the chief financial officer. The American Organization of Nurse Executives and HFMA are also offering joint educational sessions to hone financial skills key to executive success. Plans are now underway to expand the AONE/HFMA educational partnership to further develop the financial skills for the CNO.
Recognizing the growing importance and complexity of the CNO role, the AONE Nurse Executive Competencies1 were developed to provide an essential framework for curricula and professional development programs to target the knowledge and skills needed by future CNOs. As a nursing practice specialty, the nurse executive role requires proficient and competent practice specific to the role. The AONE competencies set the standard for that practice, focusing on 5 domains integral to the practice of nurse executives: leadership, knowledge of the healthcare environment, communication and relationship management, professionalism, and business skills and principles.
We found that involuntary CNO turnover is accompanied by powerful and often painful emotions, and the transition period can be difficult. However, we did not expect to hear the stories of such intense personal anguish experienced by CNOs who left their previous jobs involuntarily. Informants noted the importance of coaching and counseling during the turnover experience, especially for involuntary turnover. In response, AONE is in the process of developing a coaching resource that will be available to CNOs during this important role transition, including providing access to a network of colleagues who can offer peer support and help CNOs overcome the isolation often experienced during CNO turnover. These efforts are consistent with previous reports of nurse leaders who are turning to self-development programs and practices16 or engaging an executive or leadership "coach."17,18 Other options are to pursue leadership development through participation in national programs, such as the Johnson and Johnson Wharton Fellowship and the Robert Wood Johnson's Executive Nurse Fellows Program.
Succession planning, or identifying, guiding, and mentoring the next generation of CNOs, was also identified in this study as a needed imperative. Leadership succession planning is common in the business world and is viewed as a key strategy to prepare a pipeline of leaders to deal effectively with the future of the organization.19-21 However, findings from our study confirm those reported in a Voluntary Hospitals of America study,13 which indicated that two-thirds of the CNO respondents (more than 80% of whom were older than 46 years) reported no succession plan in place to succeed them. Therefore, major AONE initiatives are underway to address succession planning, including 3 educational programs aimed at developing the next generation of nurse executives. The Aspiring Nurse Leader Institute focuses on developing entry-level management skills and creating individual capacity for nurses who are just beginning as nurse leaders or who aspire to the nurse leadership role. The Nurse Manager Institute is designed for nurse managers who have more experience and focuses on advanced skills needed for success. Finally, the nurse manager fellowship is a year-long program for experienced nurse managers focusing on the preparation of future executive leaders. Content for all of these programs has been influenced by the findings from this study, especially the need for content in finance, relationship management, and professional resiliency.
Interestingly, one theme that we expected to emerge but did not was compensation as a reason for CNO turnover. However, one theme closely associated with compensation was the need for CNOs to be savvy regarding career security. Knowledge of employment contracts and severance packages is becoming increasingly necessary in the current environment and especially in light of increasing CEO turnover. That is, when CEO turnover occurs, incoming CEOs may desire their own "teams" and the incumbent CNO may be asked to leave. Given this potential, CNOs must be prepared to execute a severance package as part of the negotiation process before taking a CNO position. Although each severance package is individualized, key elements that protect the CNO can be included, such as severance pay and other associated expenses, including coaching, counseling, and placement assistance.
Finally, healthcare executive recruiters provided key insights into why the present healthcare environment presents a great opportunity for nursing and the CNO role. They pointed to patient safety and quality movement as a strong impetus to develop the CNO role because CNOs are the sentinels who oversee patient quality and safety.22 Another important opportunity for the CNO is leading the Magnet recognition process, a nursing initiative that has potential for marketing, garnering community support, and enhancing quality and safety.
The CNO role is critical to providing an environment in which safe quality care is delivered to patients, as well as in leading and shaping the US healthcare system of the future. In acknowledgement of CNOs' important roles, this study sought to generate information to inform the development of strategies to improve CNO recruitment and retention. Although the findings reveal that there is still much work to do, the findings indicate that this is a time of "great opportunity" for nursing and healthcare. We need to seize the opportunity.
The authors acknowledge the important contributions of the American Organization of Nurse Executives board, both in identifying a strategic initiative pertaining to chief nursing officer retention and turnover and in providing advice and consultation during the development and conduct of this study.
© 2008 Lippincott Williams & Wilkins, Inc.