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Nursing Management:
doi: 10.1097/01.NUMA.0000413097.61962.cc
Department: Leadership Q&A

Working together to achieve goals

Raso, Rosanne MS, RN, NEA-BC

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Senior Vice President of Patient Care Services and Chief Nursing Officer, Lutheran Medical Center, Brooklyn, N.Y.

Q The bargaining unit leadership team that represents the nurses who work at my hospital doesn't understand the pressures of leading a healthcare organization in these economic times. Do you have any recommendations on how I can convince them that we don't have an open checkbook?

You'd have to be living under a rock to not understand the economic pressures on healthcare organizations! Operating budget planning is constantly shifting due to multiple external factors, such as healthcare reform, accountable care organizations, health homes, value-based purchasing, unfunded regulatory mandates, and more. Your own organization's internal factors complete the budget scenario. The speed of change is unlike anything we've ever seen.

Most likely, union leaders do understand and have the resources to research it. Share your data with them to help them see the big picture; for example, the specific impacts of fiscal reform and the operating margin, volume data, income and expenses, and/or debt. Your finance and human resource departments are key. You can specify the actual cost of nurses' salaries and benefits across several years. The cost of benefits, especially health and pension, is often hidden to staff and a surprisingly large contributor to hospital expenses. Analyze the projected cost of union proposals; the annualized numbers across the organization are often surprising.

You may also have to explain any signs of perceived big spending or generous income. For example, large capital projects or charitable bequests, which are funds not available for the operating budget (where staff salary and benefits are paid), often aren't understood. Another target may be executive salary and benefits if not comparable to industry standards.

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In the end, the goals are usually the same: competitive salary and benefits and a financially viable organization. Help them understand your pressures, try to understand theirs, and work together toward mutual goals.

Q Our CNO reports to the COO and not the CEO. As a nurse leader, should I be concerned about this table of organization?

The answer really depends on the table of organization and the leadership style of the COO and CEO. I wouldn't be concerned just as a matter of reporting relationship; the CNO can be transformational either way.

Magnet® standards expect the CNO to be actively involved at the highest decision-making level and influence organization-wide changes, which can happen in both scenarios. The COO has broad operational responsibility, therefore, the CNO reporting to the COO shares in that influence organization-wide. Of course, the CEO role is more strategic. The CNO would need to be supported by the CEO, as well as the board of trustees, to be successful. This is a product of strong leadership, prioritization, communication, and relationship building, not necessarily a product of the table of organization.

To be transformational, the CNO has to be strategic, bringing the mission and values of the organization to life and pushing nursing toward excellence in quality, safety, and service. The CNO breaks down silos, facilitates labor-management relations, and creates a positive culture. Does this need COO and CEO support? Definitely. Would a micromanaging, authoritarian COO or CEO be of concern? Definitely.

I report to our hospital's COO and in her words, “no matter who one reports to, it's the individual chemistry and the sense of trust and support that makes the difference. One can report directly to the CEO without that relationship and be thwarted at all crossroads. That can be the case with COOs as well. The sense of trust, autonomy, influence, and abilities is what matters.”

The CNO is akin to the COO for nursing, regardless of reporting relationships. As long as the CNO has credible and influential relationships organization-wide and is supported by the executive team, you shouldn't be concerned.

© 2012 by Lippincott Williams & Wilkins, Inc.

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