AONE
Leadership Perspectives
JONA Volume 44, Number 12, pp 619-621 Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Leading Nursing Through Influence and Structure The System Nurse Executive Role Carol Bradley, MSN, RN As health systems consolidate, the system chief nurse executive (SCNE) role is emerging as an important and strategic member of the health system leadership team. Based on a survey of incumbent SCNEs conducted by the American Organization of Nurse Executives (AONE), this article discusses the trends in this role including the structure and function in today’s health systems. With the assistance of AONE, this group of leaders is creating a community of support and networking. Because of the broad influence of these roles, the SCNEs who serve in these roles are having a major influence on the practice of nursing in our nation’s healthcare delivery system and clinical outcomes. The role of the health system chief nurse executive (SCNE) has increased in prevalence and influence as hospitals have reorganized and consolidated into larger health systems. This
trend demonstrates an increasing recognition by system chief executive officers (CEOs) and governing boards, regarding the value and important contribution of a nursing voice at the senior leadership table at the system level.1-3 In recognition of the expanding number of SCNEs and the broad level of influence they hold, American Organization of Nurse Executives (AONE) explored how to support and recognize the unique needs of its member nurse leaders in these roles. In 2010, AONE convened a small group of SCNEs to discuss the role and develop a model set of leadership competencies based on the original AONE Nurse Executive Competencies.2 As part of the work of this group, there was a desire to survey incumbents to better understand the unique characteristics of the SCNE role in health systems.
Methodology Author Affiliation: Senior Vice President and Chief Nursing Officer, Legacy Health, Portland, Oregon; Past President, American Organization of Nurse Executives (AONE); Member, System CNE Taskforce, AONE, Washington, DC. The author declares no conflicts of interest. Correspondence: Ms Bradley, Legacy Health, 1919 NW Lovejoy, Portland, OR 97209 ([email protected]). DOI: 10.1097/NNA.0000000000000136
JONA Vol. 44, No. 12 December 2014
Initiated in 2012 and repeated in 2013 and 2014, a SCNE survey was conducted using the American Hospital Association member database, as well as the informal network of SCNEs tapping into their network of colleagues in similar roles. This survey explored role characteristics, job responsibilities, reporting rela-
tionships, and other structural aspects as well as compensation and benefits associated with the SCNE role. Demographics of SCNEs were included in the survey. Characteristics of SCNEs From the AONE Survey The number of established health system CNE roles has grown in recent years. Based on the AONE survey, more than one-third of SCNE positions have been in place for more than 10 years. Approximately half of the incumbents in this role are serving as the 1st SCNE for their employer, and they have increasing tenure in their role (Figure 1). While all SCNE roles hold crossorganizational responsibilities, approximately one-fourth to one-third also hold a chief nursing officer (CNO) in a flagship hospital in addition. This is particularly the case in systems with a small number of hospitals. Most incumbents hold the dual titles of senior vice president and CNO/CEO and, based on the peers of this role, are considered key members of the C-suite. Most SCNE incumbents have ascended to the role from a hospital CNO role and hold at least a master’s degree in nursing. Degrees in business and health administration are
619
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
AONE
Leadership Perspectives
Figure 1. SCNE tenure in position 2012-2014.
common. A little over one-third of SCNEs are doctorally prepared, holding either a PhD or DNP. Almost all SCNEs have specialty certification in nurse executive practice and/or as a healthcare executive. All those surveyed were members of AONE. Structural Relationships Similar to the hospital industry statistics, systems with SCNE positions are approximately 90% not-for-profit and are either regional or national systems. A majority of these systems are medium-sized having between 4 and 20 hospitals. However, these are also complex healthcare organizations with many additional horizontal healthcare services, including ambulatory care, outpatient surgery, urgent care, home health, hospice, retail pharmacy, skilled nursing, longterm care, wellness center, and schools of nursing. Typically, the SCNE assumes oversight of nursing care across the continuum. The SCNE role most frequently reports directly to the system president/ CEO, similar to other C-suite peers. In larger systems, this role may report to a chief operating officer. While organizational structures vary significantly based on many variables, the most frequent peers of this role include the chief medical officer, chief financial officer, chief human re-
620
sources officer, and chief technology/ information officer. In addition, the chief legal officer and chief quality officer are peers nearly 50% the time. Of all organizational relationships, the manner in which the SCNE and site-based nursing leadership relate is critically important. Nineteen percent of SCNEs lack a formal reporting relationship with their hospitalbased CNOs. The most common structure is dual reporting of the hospital-based CNO to the SCNE and the site CEO/administrative role through a matrix or dotted line relationship. It is increasingly common for the SCNE role to have a direct line to hospital CNO to better align the nursing organization in the system infrastructure.4 The span of influence of the SCNE is expansive, which translates into an increasingly concentrated number of nurse leaders at the system level that have a major impact on the practice of a large group of nurses. While the nursing span of control is directly related to the overall size of the health system, 74% of SCNEs report having a workforce of between 1000 and 15000 RNs. By comparison, the largest health systems have tens of thousands of nurses being led by a SCNE. In addition to broad responsibility for nursing across the system,
SCNEs are often directly responsible for other functions. Clinical education, academic relationships and schools of nursing if present, and care management commonly report to the SCNE. Pharmacy, clinical quality, patient safety, infection control, ambulatory clinics, and a myriad of other clinical/patient-facing services may report to this role. It is common for this role to lead key system initiatives such as patient experience. The survey demonstrated consistent characteristics that were nursing focused. For example, all SCNEs reported having a system-wide strategic plan for nursing. While only 10% of SCNEs report system-wide Magnet recognition, slightly over half have at least 1 or more hospitals that have achieved Magnet designation. Even more common is system-wide nursing shared governance, with 75% of SCNEs having oversight over this infrastructure. A
Relationship With Governance and Medical Staff Consistent with The Joint Commission standards on leadership and nursing,5 80% of SCNEs attend the health system’s governing board meetings, with over half contributing a nursing report to the agenda. Interestingly, SCNEs report that almost half of the system-governing boards have an RN as a trustee/director. In terms of credentialing of advanced practice RNs, over half of SCNEs are directly involved in the process, a responsibility that is frequently shared with the chief medical officer and medical staff leadership. Compensation and Benefits As part of the C-suite, it would be logical to expect that SCNEs have compensation and benefits that are similar to other executive colleagues (Figure 2); however, only about half
JONA Vol. 44, No. 12 December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
AONE
Leadership Perspectives
Figure 2. SCNE compensation distribution for 2013.
and supported in the healthcare leadership of AHA as well as in the membership of AONE. The role is, by nature of its system focus, uniquely different from site-based nursing leadership and represents nursing and patient care at the highest levels of healthcare organizations. It is important that this group of nursing leaders, with the support of AONE, is creating its own community of support and networking. Acknowledgments
of SCNEs report that they feel their compensation is equitable to other C-suite executives. In addition to base salary, incentive bonuses are common and may represent as much as 30% to 40% of base salary. Incentives are usually driven by goal or performancebased metrics. Thirty-four percent of SCNEs report having incentive opportunity of 30% or greater. In addition to salary and incentives, support for professional education and travel, dues and subscriptions, tuition support, enhanced retirement, and technical allowance are the most prevalent perquisites. Less common are car allowances and stock options, which are associated with the proportionately small number of for-profit systems. In addition, similar to other senior executive positions in high-risk positions, 86% of
JONA Vol. 44, No. 12 December 2014
SCNEs have severance agreements, the most prevalent time frame is 1 year or greater.
The author thanks the many SCNEs who contributed to the better understanding of this role through this data collection and dialogue.
Conclusions
REFERENCES
With the increasing focus of our nation’s health systems on population health, the role of senior nursing leaders has never been more important. System nurse executives are positioned in to ensure that nursing is represented and strategically engaged in decisions that will reshape our healthcare system and improve the health of the communities we serve. While the SCNE role is increasingly present in health systems, support for this role and its appropriate design is critical to the success and impact on nursing practice. The AONE taskforce is interested in ensuring that this role is well defined
1. Englebright J, Perlin J. The chief nurse executive role in large health systems. Nurs Adm Q. 2008;32(3):188-194. 2. Rudisill P, Thompson P. The American organization of nurse executives system CNE taskforce: a work in progress. Nurs Adm Q. 2012;36(4):289-298. 3. Clark JS. The system chief nurse executive role: sign of the changing times? Nurs Adm Q. 2012;36(4):299-305. 4. Kerfoot K, Luquire R. Alignment of the system’s chief nursing officer: staff or direct line structure. Nurs Adm Q. 2012;36(4): 325-331. 5. The Joint Commission. Chapter: leadership; standard LD.01.01.01, standard NR 01.01.01. 2009. http://www.jointcommission .org/assets/1/18/wp_leadership_standards.pdf. Accessed September 4, 2014.
621
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Leadership Perspectives
JONA Volume 44, Number 12, pp 619-621 Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Leading Nursing Through Influence and Structure The System Nurse Executive Role Carol Bradley, MSN, RN As health systems consolidate, the system chief nurse executive (SCNE) role is emerging as an important and strategic member of the health system leadership team. Based on a survey of incumbent SCNEs conducted by the American Organization of Nurse Executives (AONE), this article discusses the trends in this role including the structure and function in today’s health systems. With the assistance of AONE, this group of leaders is creating a community of support and networking. Because of the broad influence of these roles, the SCNEs who serve in these roles are having a major influence on the practice of nursing in our nation’s healthcare delivery system and clinical outcomes. The role of the health system chief nurse executive (SCNE) has increased in prevalence and influence as hospitals have reorganized and consolidated into larger health systems. This
trend demonstrates an increasing recognition by system chief executive officers (CEOs) and governing boards, regarding the value and important contribution of a nursing voice at the senior leadership table at the system level.1-3 In recognition of the expanding number of SCNEs and the broad level of influence they hold, American Organization of Nurse Executives (AONE) explored how to support and recognize the unique needs of its member nurse leaders in these roles. In 2010, AONE convened a small group of SCNEs to discuss the role and develop a model set of leadership competencies based on the original AONE Nurse Executive Competencies.2 As part of the work of this group, there was a desire to survey incumbents to better understand the unique characteristics of the SCNE role in health systems.
Methodology Author Affiliation: Senior Vice President and Chief Nursing Officer, Legacy Health, Portland, Oregon; Past President, American Organization of Nurse Executives (AONE); Member, System CNE Taskforce, AONE, Washington, DC. The author declares no conflicts of interest. Correspondence: Ms Bradley, Legacy Health, 1919 NW Lovejoy, Portland, OR 97209 ([email protected]). DOI: 10.1097/NNA.0000000000000136
JONA Vol. 44, No. 12 December 2014
Initiated in 2012 and repeated in 2013 and 2014, a SCNE survey was conducted using the American Hospital Association member database, as well as the informal network of SCNEs tapping into their network of colleagues in similar roles. This survey explored role characteristics, job responsibilities, reporting rela-
tionships, and other structural aspects as well as compensation and benefits associated with the SCNE role. Demographics of SCNEs were included in the survey. Characteristics of SCNEs From the AONE Survey The number of established health system CNE roles has grown in recent years. Based on the AONE survey, more than one-third of SCNE positions have been in place for more than 10 years. Approximately half of the incumbents in this role are serving as the 1st SCNE for their employer, and they have increasing tenure in their role (Figure 1). While all SCNE roles hold crossorganizational responsibilities, approximately one-fourth to one-third also hold a chief nursing officer (CNO) in a flagship hospital in addition. This is particularly the case in systems with a small number of hospitals. Most incumbents hold the dual titles of senior vice president and CNO/CEO and, based on the peers of this role, are considered key members of the C-suite. Most SCNE incumbents have ascended to the role from a hospital CNO role and hold at least a master’s degree in nursing. Degrees in business and health administration are
619
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
AONE
Leadership Perspectives
Figure 1. SCNE tenure in position 2012-2014.
common. A little over one-third of SCNEs are doctorally prepared, holding either a PhD or DNP. Almost all SCNEs have specialty certification in nurse executive practice and/or as a healthcare executive. All those surveyed were members of AONE. Structural Relationships Similar to the hospital industry statistics, systems with SCNE positions are approximately 90% not-for-profit and are either regional or national systems. A majority of these systems are medium-sized having between 4 and 20 hospitals. However, these are also complex healthcare organizations with many additional horizontal healthcare services, including ambulatory care, outpatient surgery, urgent care, home health, hospice, retail pharmacy, skilled nursing, longterm care, wellness center, and schools of nursing. Typically, the SCNE assumes oversight of nursing care across the continuum. The SCNE role most frequently reports directly to the system president/ CEO, similar to other C-suite peers. In larger systems, this role may report to a chief operating officer. While organizational structures vary significantly based on many variables, the most frequent peers of this role include the chief medical officer, chief financial officer, chief human re-
620
sources officer, and chief technology/ information officer. In addition, the chief legal officer and chief quality officer are peers nearly 50% the time. Of all organizational relationships, the manner in which the SCNE and site-based nursing leadership relate is critically important. Nineteen percent of SCNEs lack a formal reporting relationship with their hospitalbased CNOs. The most common structure is dual reporting of the hospital-based CNO to the SCNE and the site CEO/administrative role through a matrix or dotted line relationship. It is increasingly common for the SCNE role to have a direct line to hospital CNO to better align the nursing organization in the system infrastructure.4 The span of influence of the SCNE is expansive, which translates into an increasingly concentrated number of nurse leaders at the system level that have a major impact on the practice of a large group of nurses. While the nursing span of control is directly related to the overall size of the health system, 74% of SCNEs report having a workforce of between 1000 and 15000 RNs. By comparison, the largest health systems have tens of thousands of nurses being led by a SCNE. In addition to broad responsibility for nursing across the system,
SCNEs are often directly responsible for other functions. Clinical education, academic relationships and schools of nursing if present, and care management commonly report to the SCNE. Pharmacy, clinical quality, patient safety, infection control, ambulatory clinics, and a myriad of other clinical/patient-facing services may report to this role. It is common for this role to lead key system initiatives such as patient experience. The survey demonstrated consistent characteristics that were nursing focused. For example, all SCNEs reported having a system-wide strategic plan for nursing. While only 10% of SCNEs report system-wide Magnet recognition, slightly over half have at least 1 or more hospitals that have achieved Magnet designation. Even more common is system-wide nursing shared governance, with 75% of SCNEs having oversight over this infrastructure. A
Relationship With Governance and Medical Staff Consistent with The Joint Commission standards on leadership and nursing,5 80% of SCNEs attend the health system’s governing board meetings, with over half contributing a nursing report to the agenda. Interestingly, SCNEs report that almost half of the system-governing boards have an RN as a trustee/director. In terms of credentialing of advanced practice RNs, over half of SCNEs are directly involved in the process, a responsibility that is frequently shared with the chief medical officer and medical staff leadership. Compensation and Benefits As part of the C-suite, it would be logical to expect that SCNEs have compensation and benefits that are similar to other executive colleagues (Figure 2); however, only about half
JONA Vol. 44, No. 12 December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
AONE
Leadership Perspectives
Figure 2. SCNE compensation distribution for 2013.
and supported in the healthcare leadership of AHA as well as in the membership of AONE. The role is, by nature of its system focus, uniquely different from site-based nursing leadership and represents nursing and patient care at the highest levels of healthcare organizations. It is important that this group of nursing leaders, with the support of AONE, is creating its own community of support and networking. Acknowledgments
of SCNEs report that they feel their compensation is equitable to other C-suite executives. In addition to base salary, incentive bonuses are common and may represent as much as 30% to 40% of base salary. Incentives are usually driven by goal or performancebased metrics. Thirty-four percent of SCNEs report having incentive opportunity of 30% or greater. In addition to salary and incentives, support for professional education and travel, dues and subscriptions, tuition support, enhanced retirement, and technical allowance are the most prevalent perquisites. Less common are car allowances and stock options, which are associated with the proportionately small number of for-profit systems. In addition, similar to other senior executive positions in high-risk positions, 86% of
JONA Vol. 44, No. 12 December 2014
SCNEs have severance agreements, the most prevalent time frame is 1 year or greater.
The author thanks the many SCNEs who contributed to the better understanding of this role through this data collection and dialogue.
Conclusions
REFERENCES
With the increasing focus of our nation’s health systems on population health, the role of senior nursing leaders has never been more important. System nurse executives are positioned in to ensure that nursing is represented and strategically engaged in decisions that will reshape our healthcare system and improve the health of the communities we serve. While the SCNE role is increasingly present in health systems, support for this role and its appropriate design is critical to the success and impact on nursing practice. The AONE taskforce is interested in ensuring that this role is well defined
1. Englebright J, Perlin J. The chief nurse executive role in large health systems. Nurs Adm Q. 2008;32(3):188-194. 2. Rudisill P, Thompson P. The American organization of nurse executives system CNE taskforce: a work in progress. Nurs Adm Q. 2012;36(4):289-298. 3. Clark JS. The system chief nurse executive role: sign of the changing times? Nurs Adm Q. 2012;36(4):299-305. 4. Kerfoot K, Luquire R. Alignment of the system’s chief nursing officer: staff or direct line structure. Nurs Adm Q. 2012;36(4): 325-331. 5. The Joint Commission. Chapter: leadership; standard LD.01.01.01, standard NR 01.01.01. 2009. http://www.jointcommission .org/assets/1/18/wp_leadership_standards.pdf. Accessed September 4, 2014.
621
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
