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C-Suite Strategies for Nurse Empowerment and Executive Accountability

Bogue, Richard J., PhD, FACHE; Joseph, M. Lindell, PhD, RN, FAAN

JONA: The Journal of Nursing Administration: May 2019 - Volume 49 - Issue 5 - p 266–272
doi: 10.1097/NNA.0000000000000749

OBJECTIVE We examined C-suite executives' strategies to empower the nursing workforce and to ensure their own accountability for nursing empowerment.

BACKGROUND Leadership affects workforce empowerment. The literature provides little formal guidance on optimal strategies C-suite executives can adopt for improving nurse empowerment or ensuring leadership accountability for empowering the workforce.

METHODS A system's top 47 executives were invited to be panelists in a Delphi study. Two Delphi rounds revealed leadership strategies for embedding empowerment and strategies for assessing leadership performance in workforce empowerment.

RESULTS C-suite executives rated specific strategies higher for nursing workforce empowerment and for holding themselves accountable. Specific strategies were rated high as easier to implement and more likely to have a major impact.

CONCLUSIONS C-suite executives implementing strategies with greater impact may accelerate nursing empowerment, especially when executives also adopt their own strategies for holding themselves accountable.

Author Affiliations: Associate Clinical Professor (Dr Bogue) and Clinical Professor and Director of MSN/CNL Program (Dr Joseph), College of Nursing, The University of Iowa.

American Organization of Nurse Executives, Winter Park Health Foundation, and Florida Hospital Winter Park provided funding for this project. Dr Nancy R. Downing, Texas A&M University; Dr Diane Huber, University of Iowa; and Mr Bill Donahue provided review and comment.

The authors declare no conflicts of interest.

Correspondence: Dr Bogue, PO Box 532, Bryan, TX 77806-0532 (

In organizations, power is the capacity to get things done,1,2 creating the ability of a group to achieve its goals.3,4 Building on literature about power in organizations, nursing shared governance refers to nurse empowerment and the means of empowerment.5,6 Evidence supports nurse empowerment as a path for improving unit effectiveness, nursing-sensitive outcomes, patient safety, patient satisfaction, and care efficiency.7-9

Embedding a culture of empowerment via shared governance “requires continual support, adjustment, and evaluation… [involving]… people and procedures, if it is to make the transition to a continuously effective mechanism for all participants.”10(p297) As Anthony11 observes, “identifying gaps between the perception of shared governance and actual implementation provides a ‘road map’ for improving shared governance models.” As with other organizational culture initiatives, shared governance depends on flexible strategies to achieve a desired workplace culture.12

When leaders are comfortable with empowering strategies, workers embrace those strategies.13 What leaders say and do and consistency between their words and actions help establish a culture that workers believe in and support, embedding that culture in daily work, changing how things get done.14 Certain leadership competencies support or detract from an organizational culture exhibiting leadership effectiveness.15 Embedding an organizational culture in practice requires 3 sustained elements: formalized management activities, clear and consistent feedback, and high degrees of executive involvement.16 In brief, “approaching change management without also incorporating project management activities needed to monitor change can be compared with navigating without oversight and controls.”17(p72)

Nurse leaders are increasingly called upon to engage as key partners in organizational strategic planning for health systems and in educational settings,18-20 reflecting the critical role of nursing as healthcare adapts to pressures for performance improvement and cost containment.21 Following up on a JONA publication on C-suite executives' philosophy of empowerment,22 this article examines C-suite strategies for actualizing a culture supporting nursing shared governance. C-suite refers to senior executives with the letter C, for chief, as in chief executive officer, chief financial officer, chief operating officer, chief nursing executive (CNE), chief nursing officer, chief information officer, and their direct reports.23 For purposes of this study, C-suite executives were asked to identify strategies for: a) actively empowering the nursing workforce and strategies and b) holding themselves accountable to an ongoing process of empowerment of nurses in the shared governance model. Participants subsequently rated both sets of strategies in terms of their ease and likely impact. The study was deemed exempt by the organization's institutional review board.

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At the request of leadership of a 2400-bed, 8-hospital health system in the southern United States, the authors engaged in a program of research to examine the implementation and effectiveness of unit-level nursing practice councils recently established throughout the system.24,25 One study in this program of research unexpectedly found, in a survey of nurses and unit managers, that direct care nurses rated their own empowerment higher than nurse managers rated their own empowerment as managers.24 A follow-up study to explore how nurse and manager empowerment might best be fostered by organizational leadership (C-suite executives) employed the Delphi method to explore empowerment philosophies and strategies of C-suite executives. Previously presented results from an earlier stage of this Delphi study identified leadership empowerment philosophies and techniques for understanding staff needs for empowerment.22 Data and results presented here are from later phases of this Delphi study and focused on identifying and assessing specific strategies to actualize nurse empowerment and to hold leadership accountable for doing so.

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The Delphi method was used in this study.26,27 In Delphi, panelists expert in a specific practice or content area respond independently to rounds of questioning, with subsequent rounds designed using results from prior rounds. Through this iterative process, Delphi is well suited to identifying and evaluating core competencies among professional groups.28,29 Delphi also avoids sources of error common in live group dynamics, such as domination of results by a vocal few or group biases reinforcing preconceived notions, also known as “group think.”30

A purposive sample of 47 C-suite executives was identified from throughout the 8-hospital system. They included the CNE, a nurse vice president (VP), assistant VPs and VPs of other clinical areas, and chief executives in finance, operations, and management. Each round of online Delphi surveying was available for 3 weeks with weekly reminders during each round and 1-week pauses between rounds.

In Delphi Round 1, 24 of the 47 executives responded to at least 1 prompt gathering information on organizational leadership's philosophy of empowerment. In Round 2, 25 panelists consented and 22 offered techniques for determining the empowerment needs of the nursing workforce. Results from those rounds, previously published in JONA, described C-suite leaders' philosophy of empowerment and solicited techniques for understanding the empowerment needs of the nursing workforce.22

This article focuses on Delphi Rounds 2 and 3, which were designed to identify and evaluate best strategies for: a) actualizing empowerment and b) ensuring leadership accountability for empowerment. Round 2 participants responded to the following questions:

  • “What 1 or 2 specific actions should members of leadership, like you and your peers, take to embed and reinforce empowerment among the system's workers?”
  • “In a sentence or 2, in what specific ways should members of leadership like you and your peers assess their own performance in the empowerment of the workforce?”

For question 1, the 22 C-suite executives generated 33 distinct suggestions, which were consolidated using thematic analysis31 to 15 unique strategies for embedding and reinforcing empowerment among the nursing workforce. Question 2 generated 36 distinct suggestions, which were consolidated using thematic analysis to 9 unique strategies for assessing leadership performance in empowering the nursing workforce empowerment.

The 22 Round 2 respondents were surveyed in Round 3. Fifteen rated the 2 sets of strategies resulting from the questions above. The 2 types of strategies were rated in separate items on likely magnitude of impact (IMPACT) and ease of implementation (EASE) using 5-point Likert-type scales. Response options for IMPACT ratings (with their respective point values) were as follows: little or no impact (1), some impact (2), moderate impact (3), substantial impact (4), and very major impact (5). Response options for EASE ratings were: very hard to implement (1), difficult to implement (2), moderately easy to implement (3), easy to implement (4), and very easy to implement (5).

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C-Suite Strategies for Embedding and Reinforcing Nursing Empowerment

Table 1 presents the 15 unique strategies identified by the C-suite executives for embedding and reinforcing empowerment among the nursing workforce within a newly established shared governance model emphasizing unit-level nursing shared governance councils. The strategies are ranked in Table 1 by the sum of the C-suite executives' 2 ratings for impact and ease.

Table 1

Table 1

The average total rating for these strategies was 7.57 on a scale ranging from 2 to 10. The bottom tercile (total <7.27) includes the 4 lowest-rated strategies, including 3 of the 4 lowest-rated strategies for ease. In contrast, the top tercile (total >7.97) contains the 5 highest-rated strategies. These “best” strategies, listed below, include 4 of the 5 easiest strategies to carry out and 4 of the 5 rated as having the greatest likelihood of major impact, based on the Delphi panelists' ratings.

  • Give teams public praise for identifying and solving problems on their own.
  • Model behaviors that are congruent with the hospital's values and mission.
  • Be clear about organizational objectives, goals, mission, and performance expectations.
  • Teach managers how to coach and lead, rather than issue commands or take on all responsibilities.
  • Solicit recommendations and solutions from unit-level nursing practice councils.
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C-Suite Strategies for Leadership to Assess Their Own Performance in Nursing Empowerment

Table 2 summarizes the 9 strategies executives identified for holding themselves accountable for nurse empowerment, consolidated by thematic analysis from 36 different suggestions. Strategies are ranked from top to bottom in terms of the total rating resulting from the addition of IMPACT and EASE scores as above. We again assumed impact and ease to be of equal weight.

Table 2

Table 2

The average total rating was 6.24 on a scale ranging from 2 to 10. The top 5 strategies for assessing their own performance in nursing empowerment are remarkable because all have average ratings higher than the scale midpoint in both impact and ease. These strategies are as follows:

  • Add performance in empowering their nursing staff in key performance indicators (KPIs) for executives.
  • Use separation rates (a contributor to turnover in a nursing unit or department, separation rates refer to exiting the organization entirely) as a leading indicator of C-suite executives' performance in empowering their staff.
  • Survey staff periodically to assess executives' performance in empowering their staff.
  • Use patient and staff satisfaction scores (such as Hospital Consumer Assessment of Healthcare Providers and Systems for patient satisfaction and National Database of Nursing Quality Indicators for job satisfaction) as leading indicators of leaders' performance in empowering staff.
  • Include leaders' contributions to staff empowerment in annual 360-degree evaluations.

Total ratings were lower, and there was less dispersion across executives' ratings of strategies to assess their own performance in nursing empowerment, compared with ratings of strategies to embed empowerment among the nursing workforce. This latter point is examined further in the Discussion section using a secondary analysis.

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The C-suite executives' top 5 strategies for embedding and reinforcing empowerment (Table 1) all depend on vertical alignment24; vertical alignment occurs when different actions taken in different parts or levels of an organization drive progress toward the same goal. In other terms, vertical alignment occurs when the actions of microlevel and mesolevel actors (nursing units or departments) reflect the actions of macrolevel actors (C-suite executives).31 For example, strategy 1 charges C-suite executives with giving macrolevel praise to microlevel/mesolevel teams that identify and solve problems on their own. Strategy 5 recommends that C-suite executives ask for solutions from unit-level nursing practice councils. This suggests a general principle for ensuring effective empowerment: develop and adopt strategies that require action by top-level executives with or in consort with appropriate nursing management and staff actions at all levels of the organization. These findings, and findings elsewhere in our program of research, informed the design of the General Theory for Multilevel Shared Governance approach to nursing shared governance.22,24,25

The empowerment strategy rated highest by the Delphi panelists stands out for its very high level of ease: give teams public praise for identifying and solving problems on their own. The executives not only rated this the easiest strategy but also one that has a moderately high potential for impact. This example demonstrates the spirit and intention of nursing shared governance by focusing leadership praise on teams that identify and solve problems on their own.

C-suite executives' top strategies for holding themselves accountable for workforce empowerment focused on incorporating workforce empowerment into assessments of their own performance. That is, they rated strategies more highly if they were, or should be, related to their own KPIs, the performance indicators for which they are personally accountable. Such strategies promote aligning leaders' KPIs to include staff empowerment. In short, they emphasized evaluation of C-suite performance based on separation rates (organizational exit), patient satisfaction, and staff satisfaction. They highly recommended developing mechanisms to gather feedback directly from nurses to assess leaders' performance in empowering the workforce, including measuring leaders' contributions to staff empowerment in 360-degree evaluations. In brief, the C-suite executives in this study accepted that they must take more personal responsibility for embedding empowerment among the nursing workforce and offered meaningful strategies for holding themselves accountable.

Findings revealed lower ratings on C-suite strategies for holding themselves accountable versus their higher ratings on a comparable 5-point scale about strategies to embed empowerment. We conducted a secondary analysis to determine the size of this difference using GraphPad (QuickCalcs, La Jolla, California). The executives' ratings were significantly lower for both impact (t22 = 5.92, P < .001) and ease (t22 = 2.33, P = .029) when assessing strategies for holding themselves accountable. These differences with this small sample are quite robust. This finding suggests less confidence in the strategies they identified for holding themselves accountable. Two possibilities influencing this rating are that the C-suite executives were less familiar with the idea of holding themselves accountable for workforce empowerment, or they were less experienced with methods of doing so. This is an area for future research.

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Implications for Nursing Administration

It can be difficult to choose from a variety of possible actions for advancing nurse empowerment through a nursing shared governance model. Our findings illustrate that it is not necessary to sacrifice impact for ease or vice versa. Impact and ease can be gained by identifying and examining best strategies from various in-house leadership perspectives such as was done in this study. Findings emphasize the need for vertical alignment of behaviors, systems, and frameworks, especially within the nursing department, if shared governance is to be an effective vehicle in achieving workforce and patient outcomes; that is, goals must be shared and communicated up and down the organizational hierarchy; and while strategies for working toward goals may vary depending on an individual's or team's roles in the organization, strategies up and down the organizational hierarchy work best if mutually supporting. Leadership actions and workforce actions at the unit level and as importantly at the C-suite level can advance empowerment when programmatically and strategically aligned. C-suite executives can reinforce support of unit-level councils and outcomes as mentioned previously.

Some of the strategies rated low for ease in this study may be easier to accomplish in smaller organizations. For example, it may be easier in smaller organizations to “provide staff with the competencies and tools needed to identify and solve problems.” In this large organization, this strategy was rated high in terms of impact but very low in ease of implementation. It costs more time and effort to provide 4000 nurses with competencies and tools to identify and solve problems than to provide the same attention to 200 nurses. Therefore, larger organizations may achieve higher levels of empowerment from shared governance at the unit level as compared with more removed house-wide councils. The members of a unit council can give and receive feedback from peers more quickly and easily support more cooperation and involvement in the model. Fostering unit-level councils enables nurse managers to practice and refine skills in collaboration with each other.

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Implications for C-Suite Executives

These results reveal the highest-rated strategies for workforce empowerment from the C-suite executives in 1 large health system. Other executive teams can adopt and test these strategies in their own organizations. Alternatively, other executives might replicate the method of this study to identify their own high-impact and high-ease strategies for increasing nurse empowerment or improving other areas of performance.

In the setting for this study, we assumed impact and ease to be of equal importance. This 50/50 balance reflects the idea that consistently implementing strategies across numerous departments of a large organization requires more attention to the complexities, time, and effort required for implementation, so ease takes on great importance. Leaders in smaller organizations face relatively lower communication and coordination costs and challenges and therefore may prefer to place more weight on impact when evaluating strategies for embedding and reinforcing nursing empowerment.

Most of the executives responding through all 3 Delphi rounds had administrative responsibility for areas other than nursing. This suggests that executive leaders in domains other than nursing recognize, or can be guided to recognize, the importance of nurse empowerment. This may be especially true in larger organizations and/or when the methods used represent a modest time commitment that is both personal and directed toward strategic level decisions.

Active engagement by nursing leadership in nurse empowerment aligns well with several nurse competencies from the American Organization of Nurse Executives (AONE).32 Examples of AONE competencies exercised through this study's process and results include strategic management, human resource management, personal and professional accountability, systems thinking, change management, relationship management, patient safety, and other performance improvements.

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These results may not be generalizable to other health systems or hospitals. Organization size, differences in models of shared governance, available research assets, and leadership support vary across organizations.33

The number of panelists was suitable for a Delphi study. There was enough overlap in suggested strategies for consolidation using thematic analysis. Enough executives participated in Round 3 to statistically affirm differences in ratings of empowerment strategies versus strategies for holding themselves accountable. However, more panelists may have generated a richer set of strategies and lent greater confidence in the results.

Examining more specific elements of impact and ease might have produced more nuanced results and recommendations. For example, ease could be broken down into independent assessments of elements such as personnel time, financial costs, and degree of complexity. We solicited general ratings of impact and ease in the Delphi in consultation with executive advisors who emphasized the need to limit time demands on the C-suite executives. Examining more specific aspects of ease and impact would have cost our Delphi panelists more time and might well have reduced participation.

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Engaging C-suite executives in generating and reviewing their collective understandings creates an action potential for applying improved knowledge throughout and up and down the organization. In this case, executives across facilities and departments developed and evaluated their collective understanding and support for nursing empowerment through shared governance.

Delphi methodology can be especially useful to researchers when one aim is to help subjects gain more detailed and precise views of their shared understandings.26,27 By providing summaries of their prior results in each Delphi round, and using each round to design subsequent rounds, the executives gained common and more nuanced understandings of the concepts explored. This article focuses on engaging C-suite executives' responsibilities for supporting the empowerment of the nursing workforce. Leaders have their unique sets of roles and strategies for workforce empowerment and performance improvement. We close by emphasizing the importance of unit-level council assessment and improvement of unit-level competencies for nursing shared governance. Strong and self-empowering unit-level councils offer the prospect of powerful alliances working, with mutually supportive strategies and actions up and down the organization, in vertical alignment, to maximize performance improvement throughout a healthcare organization.21,22,24,25

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