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The Resilient Nurse Leader Reinvention After Experiencing Job Loss Mary O’Connor, PhD, RN, FACHE; Joyce Batcheller, DNP, RN, NEA-BC, FAAN The nurse executive has been especially vulnerable to unexpected job loss as a result of financial and other pressures in the health care environment. The nurse leader is often the one who holds the standards of quality and safety above those of cost. While there may be many reasons or factors that affect a sudden removal of a nurse leader, the problem is that the unexpected job loss is often a devastating and traumatic event to the individual affected. Twelve nurse executives who experienced unexpected job loss were interviewed in depth for this study. Stories collected illustrated deep personal and professional loss of identity and self-esteem as well as colleagues and friends. Their resilience and ability to get past this adversity aided the nurse leaders in their healing, recovery, and reinvention of their professional selves. Finally, following reflection, the participants offer strategies for averting unexpected job loss as well as preparing for transition. Key words: career recovery, job loss, nurse leader resilience
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HE ISSUE of unexpected job loss is not new to the most recent changes in health care. Rather, over the past decades, there have been ongoing reforms with emphasis on cost containment. While there have always been financial pressures, the challenges to reduce spending are at an all-time high, as reimbursement practices change and there are unprecedented cost-reduction needs. The nurse executive has been especially vulnerable as the one who holds the standards of quality and safety above those of cost. While there may be many reasons or factors that affect a sudden removal of a nurse leader, the problem is that the unexpected job loss is often a dev-
Author Affiliation: School of Nursing, Notre Dame of Maryland University, Baltimore (Dr O’Connor); and School of Nursing, Texas tech University Health Sciences Center, Lubbock, TX. No external funding was used for this project. The authors declare no conflict of interest. Correspondence: Mary O’Connor, PhD, RN, FACHE, School of Nursing, Notre Dame of Maryland University, 4701 North Charles St, Baltimore, MD 21210 ([email protected]). DOI: 10.1097/NAQ.0000000000000089
astating and traumatic event to the individual affected. While it might be just business, it is deeply personal. There have been a few studies of chief nursing officer (CNO) job loss, with much of it conducted in the 1990s when health care leaders were struggling with the transition from pay-for-service to prospective payment. Kippenbrock and May1 studied the factors contributing to turnover by looking at hospital characteristics and other institutional data from the American Hospital Association. They found almost a 22% turnover rate in 5 years. Later, Kippenbrock2 conducted a survey of CNOs who had left their position and CEOs who had experienced nurse executive turnover. While the subjects of this sample did not necessarily experience involuntary job loss, the perceptions of the reasons for turnover were dramatically different. For example, the CNOs (93% females) cited the lack of power to make substantive changes, the changing health care environment, and conflict with the CEO as the major professional factors in turnover. Personal factors were also reported including the lack of support and feelings of isolation. The CEOs (72% males) 123
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reported that the exiting CNOs had a lack of management skill and were unable to create an effective team. In 2006, the AONE (American Organization of Nurse Executives) and researchers from the University of North Carolina conducted a survey study to get a sense of the scope of CNO turnover.3 This survey was recently updated in 2013 and presented to the attendees of the 2014 AONE annual meeting.4 The sample included more than 600 permanent and interim CNOs. Many of the characteristics of CNOs were similar to those of the 2006 survey. One difference in the 2013 sample is that more CNOs have had more than 1 job in the role and have tenure of more than 10 years. The sample group was asked whether they experienced job turnover. Of those who did, 20% reported that the turnover was involuntary. This included those who were terminated and those whose resignations were requested. The researchers concluded by reporting professional resources that were helpful in making a transition; networking, coaching, and professional development were foremost in importance.4 After a comprehensive review of the literature,5 Batcheller6 extended the dialogue by implementing a transition process and an ongoing assessment and development program for CNOs in a hospital system. This work lead to the development of a guide for CNOs to enculturate into the role with the hopes of stabilizing and alleviating unexpected CNO turnover.6 Perhaps, the nonvoluntary termination is becoming more common. Certainly, the works by Havens et al3,4 would suggest that CNOs believe this is an urgent issue or at least one of concern. The issues of nonvoluntary termination were of interest to us, and we wanted to explore both professional and personal experiences of this phenomenon. METHODS This qualitative descriptive study explored the experience of nurse leaders who under-
went unexpected job loss. While the scope of the issue is important, the stories and trauma lived by these participants emphasize the fragility and instability of our industry. By capturing their stories, we illustrated the insight and demonstrated the resilience of these leaders and their path to reinvention. This study is important because of the critical role of nurse leaders in guiding nursing care and the delivery of health care today and in the future. The research questions were as follows: (1) How has unexpected job loss affected the personal and professional lives of the nurse leader? (2) What strategies can the nurse leader employ to reinvent her or his professional career? (3) What is the process of moving from unexpectedly unemployed nurse leader to newly successful and fulfilled nurse leader? This article addresses the first 2 questions of the study. The third question will be addressed at a later time. This study was approved by the institutional review board at Notre Dame of Maryland University. Sample To be accepted into this study, the participant needed to have experienced unexpected job loss in the role of a nurse leader (CNO, director of nursing, or other executive position), read and write English, and be willing to share her or his experiences in an interview process. Participants were recruited through colleagues known to the researchers and by use of snowball sampling. This method starts with 1 or 2 people who have experienced the condition and may refer others interested in participating.7 For example, one author is a member of the Robert Wood Johnson Fellows Program. The networking capabilities of this group were used to recruit participants. All participants meeting the criteria were welcomed into the study. There were no restrictions or exclusion by race, age, gender, ethnicity, or any other social or economic condition. Participants were recruited until data were saturated.
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The Resilient Nurse Leader Data analysis Thematic analysis was done with all interview data by both researchers separately and then compared for consistency of findings. The themes were meant to describe first the stories in aggregate and, second, to explore the processes used by the participants to recover from their experience of job loss and their subsequent reinvention of self. Rigor in qualitative research was addressed through the elements of trustworthiness and determined using the criteria offered by Lincoln and Guba8 in 1985 and still in use today. These elements are credibility, dependability, confirmability, and transferability. For credibility, Lincoln and Guba8 purport prolonged engagement with the participant and the data. The interview of 45 to 60 minutes allowed the researcher and the participant to fully explore the questions and the stories. In addition, the listening to and reading of the interview transcripts added to this data immersion. Dependability was addressed by using an inquiry audit. That is, the researchers examined both the process of data collection and analysis and the product of the themes and patterns expressed. Confirmability was accomplished through the use of an audit trail documenting all activities and conclusions in the data analysis process. The audit trail is important to confirm researcher neutrality. Finally, transferability was met, as the findings have uses beyond the actual participants. Exposing the findings in the context of other literature aided in determining transferability. FINDINGS In total, 12 interviews were conducted by the researchers. Ten were conducted by phone and 2 face-to-face. The decision to meet face-to-face was strictly geographic access. Interviews were audio taped and transcribed so that both researchers could read and listen to the stories of the participants. Most of the participants had been a CNO at the time of their unexpected job loss, but some held other positions such as executive director of nursing or
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were directors of major product line in a nontraditional hierarchal structure. Most were in their 50s or 60s; 2 were in their 40s. One male participated. The participants were from all over the continental United States. Each of the individuals who were interviewed had a master’s degree or higher. They had achieved numerous personal and professional accomplishments such as progressive role responsibility, fellowship in prestigious associations (ie, FAAN, FACHE), and/or Magnet designation. Themes emerged from reliving the data through listening to and reading the transcribed texts. The themes were as follows: loss including the grief stages of denial and anger; and recovery and reinvention of the self and the career. Loss For all the participants, this event was a devastating loss in their personal and professional lives. They have not forgotten the trauma of this loss. Their stories were vivid, recalling details of conversations happening in some instances decades prior. In her seminal work, K¨ ubler-Ross9 described 5 stages of grief and loss. Of these 5 (denial, anger, bargaining, depression, and acceptance), these participants related feeling both denial and anger at least in the beginning. The participants acknowledged that their lives revolved around their work. Nursing leadership is all consuming, and what they experienced was a sudden loss of purpose, identity, dignity, and even friends and colleagues. One participant said she felt: “Shock, I was stunned, feeling completely lost, having no purpose in life. I felt like I was treated unfairly, which made me angry, since fairness is important to me.” Another said for her this was “a life-altering event, the most traumatic in my life. I more strongly identified with my role and my job than anything else in my life.” Similarly for many, the loss was sudden and surprising, at least in the moment if not in retrospect. Their performance reviews had been outstanding, adding to the surprise. Some
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were told that they had too much influence in the organization, and others did not hear anything meaningful at all. Just “it is time” or that the new CEO “wanted to clean house.” Many described experiences that were professionally degrading. Several were told to pack up their offices and be gone by the end of the day. They were not allowed to speak to their team and, in most instances, had severance packages that included a clause that prohibited them from saying anything negative about the organization or even the truth about the nature of their departure. One participant said she was not allowed to take any materials, including documentation of projects done at other institutions that she had saved for later use. Three participants continued to work for a time in the organization under confidentiality agreements and as a condition of severance. They were not allowed to discuss the truth of their circumstances but were either cajoled or coerced into finishing projects, creating a smooth transition, or creating the illusion of free choice in resigning. Another participant expressed the feeling of being used and then discarded: You know I was really angry, I was really hurt. I had put 110% effort; I had done a lot of extra work. I had done fundraisers . . . all the foundation side of things when we were doing all the capital planning, on my own time and the kind of chop you off at the knees feeling that you get when somebody just goes and takes your job away from you.
Whether this was a complete shock or not, many felt sadness with the loss. One noted that being the “chief nurse at that place where I grew up, that was my ideal job and I really lost something.” In addition, many of the CNOs shared that their peers and colleagues started to avoid them once they became aware of their situation. Several assumed that their peers behaved this way out of fear. They did not want to be seen as unsupportive of the new leadership team and risk losing their job. They needed to be seen as aligned with the “new guard” and feared they would be viewed as being disloyal if they did reach out to them. Others felt that their colleagues just moved
on. The poet David Whyte10 describes the modern workplace as a whirling speeding environment that once halted has a profound effect on identity and sense of self. In addition, he describes the loneliness that accompanies being the only one not moving at this intense speed as everyone else in one’s professional life continues speeding along. Some felt like they were denied the opportunity to say goodbye. One said: “You know the sad thing is that I worked so hard there with all those nursing staff and they trusted me and not being able to say goodbye to any of them was disappointing.” Some also described that they felt worse after they were in touch with staff with whom they worked. It was hard to hear about the changes at the organization, especially when it involved high turnover of leaders and staff and decreased patient and staff satisfaction. One participant said: “Meanwhile, he started dismantling everything we put in place.” Some said that it would take years for the organization to recover from the changes that were made. In the meantime, patients and staff were hurting, which was hard to hear. Another had a similar story: Really sad because they closed . . . a fabulous unit, the nurses were fabulous, they (the patients) got really good care, the state closed it down because they had so many infractions and he (the boss who fired her) got fired because of that. And that would not have happened if I was still there. I would not have let that happen.
The loss, sadness, rejection, and fear experienced by these participants were palpable in their stories and went beyond their personal situation. They continued to care about their colleagues and staff, the organization, and the community despite the treatment they personally received. Their disappointment superseded their anger. Most of the participants were shocked by the actions leading up to their dismissal. Job dissatisfaction and conflicts with a new chief executive officer (CEO), chief operating officer, or new boss in general were the most common reason given for the loss of job.3
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The Resilient Nurse Leader The new person wanted to hire her or his own team. This is very common and has been the number one reason for CNO turnover for years. The reasons why newly appointed CEOs terminate the incumbent CNO are not totally understood. One common reason that a few of the participants shared is that the new CEO had a CNO they have worked with in the past that they know is aligned with their style and beliefs. Other reasons ranged from no reason to political factors, and in a few cases, the nurse leader was possibly too strong and influential in the organization. In fact, in a few of these situations, the replacement nurse leader had minimal experience and less education than the one leaving. Concern was expressed that this was intentionally done so that nursing would not be as strong on a go-forward basis. One participant said: I did visit with another senior leader and was told “they do not like smart women in this office.” The day I left the new boss announced who was taking the CNO role—she had a friend who did not have the same level of education and experience. She wanted her own team.
Another said: “He did not like that I would use data to defend things and did not like my tenure and strong relationships in the organization.” For nurses who spent their career in organizations that purport to be a caring environment, most participants noted that their leaving was engineered with a dearth of caring. A typical story: “I was told by him one day to pack up and leave my office. I was not to talk to the staff—he just wanted me out and gone.” It was not only the participants who were surprised but also most told stories that news of their departure sent shock through the organization. One participant noted: “Staff nurses were shocked and in disbelief. Nursing leaders were surprised but then scared. If he could do this to me—he could do this to them. I felt like I was a symbol to show his power and influence.” Finally, many participants verbalized a loss of trust and sense of collaboration within the C-suite. A few illustrated the values and con-
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flicts that occurred on the way to job loss: “I was actually told I would have to lose some of my ethics . . . I needed to drink the Kool-Aid.” Another noted: “It just started getting really ugly and . . . uncomfortable and I didn’t trust him anymore, I didn’t like his business ethics, I felt I was compromised in this organization.” Finally, a participant noted a difference in priorities: They truly did not value nursing—they did not value the Magnet designation and what it really is supposed to be. They just wanted the designation but they did not really understand what it takes to keep this kind of designation.
The losses to the participants illustrated by these stories reflect personal and professional implications that remain long afterward. It is not possible to accurately record the organizational losses, as these stem from only one person’s perspective. However, the loss to each participant is clearly and painfully articulated. The role of the nurse leader is all consuming, and sudden, unexpected, and involuntary loss of this role can lead to denial, anger, and sadness for the self and others. Recovery and reinvention Despite the personal and professional losses, each of these participants has achieved some recovery and has reinvented her or his career. These participants in particular were resilient enough to overcome these losses to make a difference for patient care and the health care environment. Resilience has been a concept studied through the past decades in many instances and populations.11-13 Masten13 mostly studied the concept with children and challenged the conventional thinking that this was extraordinary. Instead, resilience was thought to be a more common response to loss and adversity than the lack of resilience. In a study of adults, Bonanno11 agreed, saying that most healthy adults are able to right themselves after a traumatic event or adversity. But they do not do this in isolation. Even adults need help. The way to recovery was paved with support. In their concept analysis, Garcia-Dia et al12
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identified external and internal supports as well as key attributes that were necessary for maximum resilience. The external factors identified included family, the community, and economic resources, whereas internal factors involved the individual’s personality traits and self-help abilities.12 The participants in this study acknowledged that having a strong faith, support from family and friends, and belief in oneself were all described as being essential to the healing process. They also mentioned that mentors and talking with others who have gone through a similar experience were helpful. In addition, the participants had varying degrees of financial obligations and resources. A few were more worried about their future than others, which seemed to be related to family or social support as opposed to strictly financial pressures. All the participants had some sort of severance agreement or at least received one after a battle. Several of the participants appreciated time off to grieve, reflect, heal, and consider their next move. Many said that they actually enjoyed this forced vacation even if it was stressful at the time, not knowing the future. Four key attributes were also identified in the 2013 concept analysis of resilience.12 These were determination, rebounding, selfefficacy, and social support. Despite their loss, the participants eventually kept their heads up high. Whether spurred by pride, anger, or purpose, these nurse leaders used determination in their recovery. Rebounding is the ability to bounce back,12 commonly associated with the game of basketball when a player takes the ball after a missed shot. The rebounder has the best chance to assist the team in scoring. The nurse leaders in this study were able to recover and keep going. The experiences and accomplishments they had achieved while they had been in their nurse leader role were notable and could not be erased. The experiences, skills, and expertise they had gained were part of who they were and could be used in a different setting. One participant talked about the eventual benefits of this event:
These experiences lead me to an executive director position in a state organization, to the RWJ fellowship, and eventually to a doctoral program. So even though it was a difficult time, it has opened doors for me and paved a path I may never have followed if I wasn’t, sort of pushed into this position.
According to Bandura,14 people with high self-efficacy are motivated to deal with adversity and setbacks by making a personal commitment to overcome challenges. They are able to see positive outcomes for themselves and make it happen as opposed to dwelling in negativity and self-doubt. The participants in this study had high self-efficacy. One stated: [I] felt joy because I’m clear it was not about my talent and performance. The CEO just did not want to deal with me. I experienced a lot of things but did not experience denial, inner self-criticism (ie, it was my fault), withdrawal, or depression.
The final attribute described by Garcia-Dia et al12 was social support. Many of the participants described the value and support they received from their peers in the professional organizations and networks they had built to be extraordinary. Others felt like they were shunned and treated as though they had done something wrong. In the latter cases, the participants’ family, colleagues who have experienced similar event, and colleagues from other professional networks were the greatest supporters. One participant was able to take advantage of the time to concentrate on a new path: My professional life went on hold while I finished my doctoral courses and dissertation. I was so fortunate to have support. Otherwise I would have been on my own. I would have had to find a job while getting ready to do my dissertation, which would not be good timing for a new organization. Meanwhile, I did some adjunct teaching and I found I really liked teaching. Finally, I was hired as full-time faculty . . . . I love teaching nurses and especially adults and am thriving in the adult nursing program with nurses returning to school.
Recovery and reinvention of the self and of a career do not happen smoothly. These participants struggled with personal and professional losses as described earlier, as well as
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The Resilient Nurse Leader a blow to the professional ego. Yet, each one faced this challenge with resilience through determination, rebounding, self-efficacy, and social support. The saying of “when one door closes another one opens” was described by most of the interviewees. Many described that they had left when the organization was still functioning at a high level, for which they were proud: “It is better to leave when things are going great.” These participants ended up in roles that were more exciting and offered more opportunities than the one they had left. Most believed that they have emerged as a stronger leader. Advice to others In her theory of bureaucratic caring, Ray15 showed that it was possible to lead an organization using both humanistic and business traits. While it may not be possible to control others at the table, the nurse leaders in this study were committed to a way of being that incorporated caring throughout the organization. When asked to pass along the advice they would give to friends and colleagues seeking to move into a senior leadership role, most of them agreed that despite their challenges, they would recommend that others pursue a CNO role. They affirmed that it was a rewarding role and allowed the nurse leader to be creative and innovative in the balance of caring for the community and contributing to the business of care. One participant noted: “Through the experience of being a leader as a chief nurse I discovered that I could be a good leader and a change agent and I could support the staff and the patients at the same time.” Practical business When asked for advice for aspiring CNOs, most participants in this study said, first, that candidates should always negotiate a contract at the time of hire that included 1 year of severance including salary and benefits, bonuses due, and outplacement services. This is essential since it takes time to heal and at that level it is not advisable to jump into another position right away. In addition, if
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relocation is not an option, choices may be limited. Second, the participants urged that nurse leaders engage in self-reflection as a way to determine areas needing education or development. One participant suggested: “Stay at the cutting edge—always be relevant.” Ways to stay informed include keeping up with a professional network. All the participants had a strong supportive network through professional associations, academic work, or community projects. These networks cannot be overstated in their benefits such as mentoring and opening doors to new opportunities. When seeking a position, one participant advised: “Reflect on your deepest values and assess the alignment with the organization as well as with key leaders in the organization.” Another quipped: “Think of your job as an adventure. You need to have the curiosity to look around that next corner. It is important to have an adventurous spirit.” Once in a new role, one participant advised candidates, “Get executive coaching. Often nurse leaders are in roles without peers. A coach can help you strategize in a way that others in the organization cannot.” Another spoke about assessing the landscape of a new organization before making changes too fast. She suggested those in new leadership positions practice “listening, then talking” and “ask questions” to learn the culture and nature of relationships. Warning signs While many of the nurse leaders expressed that they were surprised by their job loss, in hindsight, they could identify warning signs they should have seen. For example, some had increasing lack of support from their boss, were excluded from key executive meetings and decision-making events, and experienced an inability to get appointments with their boss. These warning signs were also identified in a similar study on CNO job loss that was completed in 1995.16 Additional factors they identified include frequent clashes with superiors, peers, and physicians and increasing
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philosophical differences with organization policies and decisions. Keeping alert for these kinds of warning signs can assist nurse leaders in being more prepared for possible job loss and help them plan for their transition more proactively. Conclusion Having resilience and being able to reinvent oneself will be key competencies nurse leaders will need as health care continues to undergo many challenges. Health care is complex and is experiencing unprecedented pressures with health reform, decreasing reimbursement, and a greater focus on outcomes. Consolidation of organizations and changes in the senior executive suite are becoming more and more common. Hospital CEO turnover increased to 20% in 2013,17 which was the highest rate since 1981. In addition, the medium tenure for a hospital CEO is just less than 4 years and one-half of an executive team will turnover within 18 months of the start date of the new CEO.18
This kind of recent data illustrates that more CNOs may in fact experience an unexpected job loss. Resilience has always been an important part of a successful organization and an important competency leaders need to have. Resilience has to do with emotional adaptability to change and the social connections that are critical to move a change forward. Resiliency can be achieved by knowing yourself through emotional intelligence tools and by thinking of an issue in terms of “possibilities” instead of “problem language.”19 Most of the CNOs who were interviewed experienced an unexpected job loss and had a sense of loss from their experience. They all demonstrated resilience. The type of role they moved to varied: some went on to another CNO role, and others went into a different role. What they all had in common is that their new role was very gratifying. The authors believe that it was helpful for them to share their experiences in a confidential manner and by doing so it may help others.
REFERENCES 1. Kippenbrock TA, May FE. Turnover at the top: CNOs and hospital characteristics. Nurs Manage. 1994; 25(9):54-57. 2. Kippenbrock TA. Turnover of hospital chief nursing officers. Nurs Econ. 1995;13(6):330-336. 3. Jones CB, Havens DS, Thompson PA. Chief nursing officer retention and turnover: a crisis brewing? Results of a national survey. J Healthc Manage. 2008;53(2):89-106. 4. Havens DS, Jones CB, Carlson J. Chief nursing officer retention & turnover, 2013: is the crisis still brewing? Paper presented at: AONE Annual Meeting; 2014; Orlando, FL. 5. Batcheller JA. Chief nursing officer turnover: an analysis of the literature. Nurs Clin North Am. 2010; 45(1):11-31. 6. Batcheller JA. On-boarding and enculturation of new chief nursing officers. J Nurs Adm. 2011;41(5):235239. 7. Polit D, Beck C. Nursing Research: Generating and Assessing Evidence for Nursing Practice. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.
8. Lincoln YS, Guba EG. Naturalistic Inquiry. Beverly Hills, CA: Sage; 1985. 9. K¨ ubler-Ross E. On Death and Dying. New York, NY: Macmillan Publishing; 1977. 10. Whyte D. Crossing the Unknown Sea; Work as a Pilgrimage of Identity. New York, NY: Riverhead Books; 2001:117-119. 11. Bonanno GA. Loss, trauma, and human resilience: have we underestimated the human capacity to thrive after extremely aversive events? Am Psychol. 2004;59:20-28. 12. Garcia-Dia MJ, DiNapoli JM, Garcia-Ona L, Jakubowski R, O’Flaherty D. Concept analysis: resilience. Arch Psychiatr Nurs. 2013;27(6):264270. 13. Masten AS. Ordinary magic: resilience processes in development. Am Psychol. 2001;56(3):227-238. 14. Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall; 1986. 15. Ray M. The theory of bureaucratic caring for nursing practices in the organizational culture. Nurs Adm Q. 1989;13(2):31-42.
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The Resilient Nurse Leader 16. Carroll TL, DiVincenti M, Show EV. Nurse executive job loss: trauma or transition. Nurs Adm Q. 1995;19(4):11-17. 17. American College of Healthcare Executives. Report of CEO turnover. http://www.ache.org/pubs/ Releases/2014/hospital_ceo_turnover_rate14.cfm. Published March 2014. Accessed November 10, 2014.
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18. Sinott DJ. Recruiting industry’s little secret. Becker’s Hospital Review, Leadership and management, October 27, 2014. Retrieved from http://www .beckershospitalreview.com. Accessed November 17, 2014. 19. Buell JM. The resilient leader: mind, body and soul. Healthc Exec. 2014;29(6):11-18.
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Nurs Admin Q Vol. 39, No. 2, pp. 123–131 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
The Resilient Nurse Leader Reinvention After Experiencing Job Loss Mary O’Connor, PhD, RN, FACHE; Joyce Batcheller, DNP, RN, NEA-BC, FAAN The nurse executive has been especially vulnerable to unexpected job loss as a result of financial and other pressures in the health care environment. The nurse leader is often the one who holds the standards of quality and safety above those of cost. While there may be many reasons or factors that affect a sudden removal of a nurse leader, the problem is that the unexpected job loss is often a devastating and traumatic event to the individual affected. Twelve nurse executives who experienced unexpected job loss were interviewed in depth for this study. Stories collected illustrated deep personal and professional loss of identity and self-esteem as well as colleagues and friends. Their resilience and ability to get past this adversity aided the nurse leaders in their healing, recovery, and reinvention of their professional selves. Finally, following reflection, the participants offer strategies for averting unexpected job loss as well as preparing for transition. Key words: career recovery, job loss, nurse leader resilience
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HE ISSUE of unexpected job loss is not new to the most recent changes in health care. Rather, over the past decades, there have been ongoing reforms with emphasis on cost containment. While there have always been financial pressures, the challenges to reduce spending are at an all-time high, as reimbursement practices change and there are unprecedented cost-reduction needs. The nurse executive has been especially vulnerable as the one who holds the standards of quality and safety above those of cost. While there may be many reasons or factors that affect a sudden removal of a nurse leader, the problem is that the unexpected job loss is often a dev-
Author Affiliation: School of Nursing, Notre Dame of Maryland University, Baltimore (Dr O’Connor); and School of Nursing, Texas tech University Health Sciences Center, Lubbock, TX. No external funding was used for this project. The authors declare no conflict of interest. Correspondence: Mary O’Connor, PhD, RN, FACHE, School of Nursing, Notre Dame of Maryland University, 4701 North Charles St, Baltimore, MD 21210 ([email protected]). DOI: 10.1097/NAQ.0000000000000089
astating and traumatic event to the individual affected. While it might be just business, it is deeply personal. There have been a few studies of chief nursing officer (CNO) job loss, with much of it conducted in the 1990s when health care leaders were struggling with the transition from pay-for-service to prospective payment. Kippenbrock and May1 studied the factors contributing to turnover by looking at hospital characteristics and other institutional data from the American Hospital Association. They found almost a 22% turnover rate in 5 years. Later, Kippenbrock2 conducted a survey of CNOs who had left their position and CEOs who had experienced nurse executive turnover. While the subjects of this sample did not necessarily experience involuntary job loss, the perceptions of the reasons for turnover were dramatically different. For example, the CNOs (93% females) cited the lack of power to make substantive changes, the changing health care environment, and conflict with the CEO as the major professional factors in turnover. Personal factors were also reported including the lack of support and feelings of isolation. The CEOs (72% males) 123
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reported that the exiting CNOs had a lack of management skill and were unable to create an effective team. In 2006, the AONE (American Organization of Nurse Executives) and researchers from the University of North Carolina conducted a survey study to get a sense of the scope of CNO turnover.3 This survey was recently updated in 2013 and presented to the attendees of the 2014 AONE annual meeting.4 The sample included more than 600 permanent and interim CNOs. Many of the characteristics of CNOs were similar to those of the 2006 survey. One difference in the 2013 sample is that more CNOs have had more than 1 job in the role and have tenure of more than 10 years. The sample group was asked whether they experienced job turnover. Of those who did, 20% reported that the turnover was involuntary. This included those who were terminated and those whose resignations were requested. The researchers concluded by reporting professional resources that were helpful in making a transition; networking, coaching, and professional development were foremost in importance.4 After a comprehensive review of the literature,5 Batcheller6 extended the dialogue by implementing a transition process and an ongoing assessment and development program for CNOs in a hospital system. This work lead to the development of a guide for CNOs to enculturate into the role with the hopes of stabilizing and alleviating unexpected CNO turnover.6 Perhaps, the nonvoluntary termination is becoming more common. Certainly, the works by Havens et al3,4 would suggest that CNOs believe this is an urgent issue or at least one of concern. The issues of nonvoluntary termination were of interest to us, and we wanted to explore both professional and personal experiences of this phenomenon. METHODS This qualitative descriptive study explored the experience of nurse leaders who under-
went unexpected job loss. While the scope of the issue is important, the stories and trauma lived by these participants emphasize the fragility and instability of our industry. By capturing their stories, we illustrated the insight and demonstrated the resilience of these leaders and their path to reinvention. This study is important because of the critical role of nurse leaders in guiding nursing care and the delivery of health care today and in the future. The research questions were as follows: (1) How has unexpected job loss affected the personal and professional lives of the nurse leader? (2) What strategies can the nurse leader employ to reinvent her or his professional career? (3) What is the process of moving from unexpectedly unemployed nurse leader to newly successful and fulfilled nurse leader? This article addresses the first 2 questions of the study. The third question will be addressed at a later time. This study was approved by the institutional review board at Notre Dame of Maryland University. Sample To be accepted into this study, the participant needed to have experienced unexpected job loss in the role of a nurse leader (CNO, director of nursing, or other executive position), read and write English, and be willing to share her or his experiences in an interview process. Participants were recruited through colleagues known to the researchers and by use of snowball sampling. This method starts with 1 or 2 people who have experienced the condition and may refer others interested in participating.7 For example, one author is a member of the Robert Wood Johnson Fellows Program. The networking capabilities of this group were used to recruit participants. All participants meeting the criteria were welcomed into the study. There were no restrictions or exclusion by race, age, gender, ethnicity, or any other social or economic condition. Participants were recruited until data were saturated.
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The Resilient Nurse Leader Data analysis Thematic analysis was done with all interview data by both researchers separately and then compared for consistency of findings. The themes were meant to describe first the stories in aggregate and, second, to explore the processes used by the participants to recover from their experience of job loss and their subsequent reinvention of self. Rigor in qualitative research was addressed through the elements of trustworthiness and determined using the criteria offered by Lincoln and Guba8 in 1985 and still in use today. These elements are credibility, dependability, confirmability, and transferability. For credibility, Lincoln and Guba8 purport prolonged engagement with the participant and the data. The interview of 45 to 60 minutes allowed the researcher and the participant to fully explore the questions and the stories. In addition, the listening to and reading of the interview transcripts added to this data immersion. Dependability was addressed by using an inquiry audit. That is, the researchers examined both the process of data collection and analysis and the product of the themes and patterns expressed. Confirmability was accomplished through the use of an audit trail documenting all activities and conclusions in the data analysis process. The audit trail is important to confirm researcher neutrality. Finally, transferability was met, as the findings have uses beyond the actual participants. Exposing the findings in the context of other literature aided in determining transferability. FINDINGS In total, 12 interviews were conducted by the researchers. Ten were conducted by phone and 2 face-to-face. The decision to meet face-to-face was strictly geographic access. Interviews were audio taped and transcribed so that both researchers could read and listen to the stories of the participants. Most of the participants had been a CNO at the time of their unexpected job loss, but some held other positions such as executive director of nursing or
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were directors of major product line in a nontraditional hierarchal structure. Most were in their 50s or 60s; 2 were in their 40s. One male participated. The participants were from all over the continental United States. Each of the individuals who were interviewed had a master’s degree or higher. They had achieved numerous personal and professional accomplishments such as progressive role responsibility, fellowship in prestigious associations (ie, FAAN, FACHE), and/or Magnet designation. Themes emerged from reliving the data through listening to and reading the transcribed texts. The themes were as follows: loss including the grief stages of denial and anger; and recovery and reinvention of the self and the career. Loss For all the participants, this event was a devastating loss in their personal and professional lives. They have not forgotten the trauma of this loss. Their stories were vivid, recalling details of conversations happening in some instances decades prior. In her seminal work, K¨ ubler-Ross9 described 5 stages of grief and loss. Of these 5 (denial, anger, bargaining, depression, and acceptance), these participants related feeling both denial and anger at least in the beginning. The participants acknowledged that their lives revolved around their work. Nursing leadership is all consuming, and what they experienced was a sudden loss of purpose, identity, dignity, and even friends and colleagues. One participant said she felt: “Shock, I was stunned, feeling completely lost, having no purpose in life. I felt like I was treated unfairly, which made me angry, since fairness is important to me.” Another said for her this was “a life-altering event, the most traumatic in my life. I more strongly identified with my role and my job than anything else in my life.” Similarly for many, the loss was sudden and surprising, at least in the moment if not in retrospect. Their performance reviews had been outstanding, adding to the surprise. Some
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were told that they had too much influence in the organization, and others did not hear anything meaningful at all. Just “it is time” or that the new CEO “wanted to clean house.” Many described experiences that were professionally degrading. Several were told to pack up their offices and be gone by the end of the day. They were not allowed to speak to their team and, in most instances, had severance packages that included a clause that prohibited them from saying anything negative about the organization or even the truth about the nature of their departure. One participant said she was not allowed to take any materials, including documentation of projects done at other institutions that she had saved for later use. Three participants continued to work for a time in the organization under confidentiality agreements and as a condition of severance. They were not allowed to discuss the truth of their circumstances but were either cajoled or coerced into finishing projects, creating a smooth transition, or creating the illusion of free choice in resigning. Another participant expressed the feeling of being used and then discarded: You know I was really angry, I was really hurt. I had put 110% effort; I had done a lot of extra work. I had done fundraisers . . . all the foundation side of things when we were doing all the capital planning, on my own time and the kind of chop you off at the knees feeling that you get when somebody just goes and takes your job away from you.
Whether this was a complete shock or not, many felt sadness with the loss. One noted that being the “chief nurse at that place where I grew up, that was my ideal job and I really lost something.” In addition, many of the CNOs shared that their peers and colleagues started to avoid them once they became aware of their situation. Several assumed that their peers behaved this way out of fear. They did not want to be seen as unsupportive of the new leadership team and risk losing their job. They needed to be seen as aligned with the “new guard” and feared they would be viewed as being disloyal if they did reach out to them. Others felt that their colleagues just moved
on. The poet David Whyte10 describes the modern workplace as a whirling speeding environment that once halted has a profound effect on identity and sense of self. In addition, he describes the loneliness that accompanies being the only one not moving at this intense speed as everyone else in one’s professional life continues speeding along. Some felt like they were denied the opportunity to say goodbye. One said: “You know the sad thing is that I worked so hard there with all those nursing staff and they trusted me and not being able to say goodbye to any of them was disappointing.” Some also described that they felt worse after they were in touch with staff with whom they worked. It was hard to hear about the changes at the organization, especially when it involved high turnover of leaders and staff and decreased patient and staff satisfaction. One participant said: “Meanwhile, he started dismantling everything we put in place.” Some said that it would take years for the organization to recover from the changes that were made. In the meantime, patients and staff were hurting, which was hard to hear. Another had a similar story: Really sad because they closed . . . a fabulous unit, the nurses were fabulous, they (the patients) got really good care, the state closed it down because they had so many infractions and he (the boss who fired her) got fired because of that. And that would not have happened if I was still there. I would not have let that happen.
The loss, sadness, rejection, and fear experienced by these participants were palpable in their stories and went beyond their personal situation. They continued to care about their colleagues and staff, the organization, and the community despite the treatment they personally received. Their disappointment superseded their anger. Most of the participants were shocked by the actions leading up to their dismissal. Job dissatisfaction and conflicts with a new chief executive officer (CEO), chief operating officer, or new boss in general were the most common reason given for the loss of job.3
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The Resilient Nurse Leader The new person wanted to hire her or his own team. This is very common and has been the number one reason for CNO turnover for years. The reasons why newly appointed CEOs terminate the incumbent CNO are not totally understood. One common reason that a few of the participants shared is that the new CEO had a CNO they have worked with in the past that they know is aligned with their style and beliefs. Other reasons ranged from no reason to political factors, and in a few cases, the nurse leader was possibly too strong and influential in the organization. In fact, in a few of these situations, the replacement nurse leader had minimal experience and less education than the one leaving. Concern was expressed that this was intentionally done so that nursing would not be as strong on a go-forward basis. One participant said: I did visit with another senior leader and was told “they do not like smart women in this office.” The day I left the new boss announced who was taking the CNO role—she had a friend who did not have the same level of education and experience. She wanted her own team.
Another said: “He did not like that I would use data to defend things and did not like my tenure and strong relationships in the organization.” For nurses who spent their career in organizations that purport to be a caring environment, most participants noted that their leaving was engineered with a dearth of caring. A typical story: “I was told by him one day to pack up and leave my office. I was not to talk to the staff—he just wanted me out and gone.” It was not only the participants who were surprised but also most told stories that news of their departure sent shock through the organization. One participant noted: “Staff nurses were shocked and in disbelief. Nursing leaders were surprised but then scared. If he could do this to me—he could do this to them. I felt like I was a symbol to show his power and influence.” Finally, many participants verbalized a loss of trust and sense of collaboration within the C-suite. A few illustrated the values and con-
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flicts that occurred on the way to job loss: “I was actually told I would have to lose some of my ethics . . . I needed to drink the Kool-Aid.” Another noted: “It just started getting really ugly and . . . uncomfortable and I didn’t trust him anymore, I didn’t like his business ethics, I felt I was compromised in this organization.” Finally, a participant noted a difference in priorities: They truly did not value nursing—they did not value the Magnet designation and what it really is supposed to be. They just wanted the designation but they did not really understand what it takes to keep this kind of designation.
The losses to the participants illustrated by these stories reflect personal and professional implications that remain long afterward. It is not possible to accurately record the organizational losses, as these stem from only one person’s perspective. However, the loss to each participant is clearly and painfully articulated. The role of the nurse leader is all consuming, and sudden, unexpected, and involuntary loss of this role can lead to denial, anger, and sadness for the self and others. Recovery and reinvention Despite the personal and professional losses, each of these participants has achieved some recovery and has reinvented her or his career. These participants in particular were resilient enough to overcome these losses to make a difference for patient care and the health care environment. Resilience has been a concept studied through the past decades in many instances and populations.11-13 Masten13 mostly studied the concept with children and challenged the conventional thinking that this was extraordinary. Instead, resilience was thought to be a more common response to loss and adversity than the lack of resilience. In a study of adults, Bonanno11 agreed, saying that most healthy adults are able to right themselves after a traumatic event or adversity. But they do not do this in isolation. Even adults need help. The way to recovery was paved with support. In their concept analysis, Garcia-Dia et al12
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identified external and internal supports as well as key attributes that were necessary for maximum resilience. The external factors identified included family, the community, and economic resources, whereas internal factors involved the individual’s personality traits and self-help abilities.12 The participants in this study acknowledged that having a strong faith, support from family and friends, and belief in oneself were all described as being essential to the healing process. They also mentioned that mentors and talking with others who have gone through a similar experience were helpful. In addition, the participants had varying degrees of financial obligations and resources. A few were more worried about their future than others, which seemed to be related to family or social support as opposed to strictly financial pressures. All the participants had some sort of severance agreement or at least received one after a battle. Several of the participants appreciated time off to grieve, reflect, heal, and consider their next move. Many said that they actually enjoyed this forced vacation even if it was stressful at the time, not knowing the future. Four key attributes were also identified in the 2013 concept analysis of resilience.12 These were determination, rebounding, selfefficacy, and social support. Despite their loss, the participants eventually kept their heads up high. Whether spurred by pride, anger, or purpose, these nurse leaders used determination in their recovery. Rebounding is the ability to bounce back,12 commonly associated with the game of basketball when a player takes the ball after a missed shot. The rebounder has the best chance to assist the team in scoring. The nurse leaders in this study were able to recover and keep going. The experiences and accomplishments they had achieved while they had been in their nurse leader role were notable and could not be erased. The experiences, skills, and expertise they had gained were part of who they were and could be used in a different setting. One participant talked about the eventual benefits of this event:
These experiences lead me to an executive director position in a state organization, to the RWJ fellowship, and eventually to a doctoral program. So even though it was a difficult time, it has opened doors for me and paved a path I may never have followed if I wasn’t, sort of pushed into this position.
According to Bandura,14 people with high self-efficacy are motivated to deal with adversity and setbacks by making a personal commitment to overcome challenges. They are able to see positive outcomes for themselves and make it happen as opposed to dwelling in negativity and self-doubt. The participants in this study had high self-efficacy. One stated: [I] felt joy because I’m clear it was not about my talent and performance. The CEO just did not want to deal with me. I experienced a lot of things but did not experience denial, inner self-criticism (ie, it was my fault), withdrawal, or depression.
The final attribute described by Garcia-Dia et al12 was social support. Many of the participants described the value and support they received from their peers in the professional organizations and networks they had built to be extraordinary. Others felt like they were shunned and treated as though they had done something wrong. In the latter cases, the participants’ family, colleagues who have experienced similar event, and colleagues from other professional networks were the greatest supporters. One participant was able to take advantage of the time to concentrate on a new path: My professional life went on hold while I finished my doctoral courses and dissertation. I was so fortunate to have support. Otherwise I would have been on my own. I would have had to find a job while getting ready to do my dissertation, which would not be good timing for a new organization. Meanwhile, I did some adjunct teaching and I found I really liked teaching. Finally, I was hired as full-time faculty . . . . I love teaching nurses and especially adults and am thriving in the adult nursing program with nurses returning to school.
Recovery and reinvention of the self and of a career do not happen smoothly. These participants struggled with personal and professional losses as described earlier, as well as
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The Resilient Nurse Leader a blow to the professional ego. Yet, each one faced this challenge with resilience through determination, rebounding, self-efficacy, and social support. The saying of “when one door closes another one opens” was described by most of the interviewees. Many described that they had left when the organization was still functioning at a high level, for which they were proud: “It is better to leave when things are going great.” These participants ended up in roles that were more exciting and offered more opportunities than the one they had left. Most believed that they have emerged as a stronger leader. Advice to others In her theory of bureaucratic caring, Ray15 showed that it was possible to lead an organization using both humanistic and business traits. While it may not be possible to control others at the table, the nurse leaders in this study were committed to a way of being that incorporated caring throughout the organization. When asked to pass along the advice they would give to friends and colleagues seeking to move into a senior leadership role, most of them agreed that despite their challenges, they would recommend that others pursue a CNO role. They affirmed that it was a rewarding role and allowed the nurse leader to be creative and innovative in the balance of caring for the community and contributing to the business of care. One participant noted: “Through the experience of being a leader as a chief nurse I discovered that I could be a good leader and a change agent and I could support the staff and the patients at the same time.” Practical business When asked for advice for aspiring CNOs, most participants in this study said, first, that candidates should always negotiate a contract at the time of hire that included 1 year of severance including salary and benefits, bonuses due, and outplacement services. This is essential since it takes time to heal and at that level it is not advisable to jump into another position right away. In addition, if
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relocation is not an option, choices may be limited. Second, the participants urged that nurse leaders engage in self-reflection as a way to determine areas needing education or development. One participant suggested: “Stay at the cutting edge—always be relevant.” Ways to stay informed include keeping up with a professional network. All the participants had a strong supportive network through professional associations, academic work, or community projects. These networks cannot be overstated in their benefits such as mentoring and opening doors to new opportunities. When seeking a position, one participant advised: “Reflect on your deepest values and assess the alignment with the organization as well as with key leaders in the organization.” Another quipped: “Think of your job as an adventure. You need to have the curiosity to look around that next corner. It is important to have an adventurous spirit.” Once in a new role, one participant advised candidates, “Get executive coaching. Often nurse leaders are in roles without peers. A coach can help you strategize in a way that others in the organization cannot.” Another spoke about assessing the landscape of a new organization before making changes too fast. She suggested those in new leadership positions practice “listening, then talking” and “ask questions” to learn the culture and nature of relationships. Warning signs While many of the nurse leaders expressed that they were surprised by their job loss, in hindsight, they could identify warning signs they should have seen. For example, some had increasing lack of support from their boss, were excluded from key executive meetings and decision-making events, and experienced an inability to get appointments with their boss. These warning signs were also identified in a similar study on CNO job loss that was completed in 1995.16 Additional factors they identified include frequent clashes with superiors, peers, and physicians and increasing
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philosophical differences with organization policies and decisions. Keeping alert for these kinds of warning signs can assist nurse leaders in being more prepared for possible job loss and help them plan for their transition more proactively. Conclusion Having resilience and being able to reinvent oneself will be key competencies nurse leaders will need as health care continues to undergo many challenges. Health care is complex and is experiencing unprecedented pressures with health reform, decreasing reimbursement, and a greater focus on outcomes. Consolidation of organizations and changes in the senior executive suite are becoming more and more common. Hospital CEO turnover increased to 20% in 2013,17 which was the highest rate since 1981. In addition, the medium tenure for a hospital CEO is just less than 4 years and one-half of an executive team will turnover within 18 months of the start date of the new CEO.18
This kind of recent data illustrates that more CNOs may in fact experience an unexpected job loss. Resilience has always been an important part of a successful organization and an important competency leaders need to have. Resilience has to do with emotional adaptability to change and the social connections that are critical to move a change forward. Resiliency can be achieved by knowing yourself through emotional intelligence tools and by thinking of an issue in terms of “possibilities” instead of “problem language.”19 Most of the CNOs who were interviewed experienced an unexpected job loss and had a sense of loss from their experience. They all demonstrated resilience. The type of role they moved to varied: some went on to another CNO role, and others went into a different role. What they all had in common is that their new role was very gratifying. The authors believe that it was helpful for them to share their experiences in a confidential manner and by doing so it may help others.
REFERENCES 1. Kippenbrock TA, May FE. Turnover at the top: CNOs and hospital characteristics. Nurs Manage. 1994; 25(9):54-57. 2. Kippenbrock TA. Turnover of hospital chief nursing officers. Nurs Econ. 1995;13(6):330-336. 3. Jones CB, Havens DS, Thompson PA. Chief nursing officer retention and turnover: a crisis brewing? Results of a national survey. J Healthc Manage. 2008;53(2):89-106. 4. Havens DS, Jones CB, Carlson J. Chief nursing officer retention & turnover, 2013: is the crisis still brewing? Paper presented at: AONE Annual Meeting; 2014; Orlando, FL. 5. Batcheller JA. Chief nursing officer turnover: an analysis of the literature. Nurs Clin North Am. 2010; 45(1):11-31. 6. Batcheller JA. On-boarding and enculturation of new chief nursing officers. J Nurs Adm. 2011;41(5):235239. 7. Polit D, Beck C. Nursing Research: Generating and Assessing Evidence for Nursing Practice. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.
8. Lincoln YS, Guba EG. Naturalistic Inquiry. Beverly Hills, CA: Sage; 1985. 9. K¨ ubler-Ross E. On Death and Dying. New York, NY: Macmillan Publishing; 1977. 10. Whyte D. Crossing the Unknown Sea; Work as a Pilgrimage of Identity. New York, NY: Riverhead Books; 2001:117-119. 11. Bonanno GA. Loss, trauma, and human resilience: have we underestimated the human capacity to thrive after extremely aversive events? Am Psychol. 2004;59:20-28. 12. Garcia-Dia MJ, DiNapoli JM, Garcia-Ona L, Jakubowski R, O’Flaherty D. Concept analysis: resilience. Arch Psychiatr Nurs. 2013;27(6):264270. 13. Masten AS. Ordinary magic: resilience processes in development. Am Psychol. 2001;56(3):227-238. 14. Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall; 1986. 15. Ray M. The theory of bureaucratic caring for nursing practices in the organizational culture. Nurs Adm Q. 1989;13(2):31-42.
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The Resilient Nurse Leader 16. Carroll TL, DiVincenti M, Show EV. Nurse executive job loss: trauma or transition. Nurs Adm Q. 1995;19(4):11-17. 17. American College of Healthcare Executives. Report of CEO turnover. http://www.ache.org/pubs/ Releases/2014/hospital_ceo_turnover_rate14.cfm. Published March 2014. Accessed November 10, 2014.
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18. Sinott DJ. Recruiting industry’s little secret. Becker’s Hospital Review, Leadership and management, October 27, 2014. Retrieved from http://www .beckershospitalreview.com. Accessed November 17, 2014. 19. Buell JM. The resilient leader: mind, body and soul. Healthc Exec. 2014;29(6):11-18.
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