February 2007

Grant Results

SUMMARY

The Health Research Educational Trust (HRET), through the American Organization of Nurse Executives' Patient Research and Education Institute (AONE Institute), conducted a study to explore hospital Chief Nursing Officer (CNO) turnover and its impact on the nursing workforce and the quality of hospital care.

Key Findings

  • About 39 percent of CNOs had left a CNO position (77 percent voluntarily and 23 percent involuntarily).
    • Voluntary reasons for leaving were: another CNO position, career advancement or development, conflicts with the CEO, job dissatisfaction or family/personal reasons.
    • Involuntary reasons for leaving included being asked to resign or terminated; mergers, downsizing or restructuring; and family/personal reasons.
  • About 62 percent of CNOs expect to change jobs within five years.

Funding
The Robert Wood Johnson Foundation (RWJF) provided $46,200 to support this unsolicited project from December 2004 through June 2006.

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THE PROBLEM

Since the late 1990s, the nursing shortage has received a great deal of attention. Although researchers have conducted many studies on recruitment and retention of staff nurses, there had been little focus on how turnover of CNOs might affect the nursing shortage.

CNOs represent the nursing staff at the senior level of hospitals and health systems and play a key role in the ability to recruit and retain nurses. By 2004, anecdotal evidence suggested an increase in involuntary CNO turnover and dissatisfaction, according to researchers at the American Organization of Nurse Executives, a subsidiary of the American Hospital Association that represents more than 5,000 nurses.

The American Organization of Nurse Executives (AONE) conducts research and special projects through its Patient Research and Education Institute (AONE Institute), which is a unit within the Health Research Educational Trust, a not-for-profit organization involved in research, education and demonstration programs addressing health management and policy issues. The Health Research Educational Trust is an affiliate of the American Hospital Association.

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RWJF STRATEGY

This grant fits with RWJF's strategic objective in its nursing work: by 2013, reduce the shortage in nurse staffing and improve the quality of nursing-related care by transforming the way care is delivered at the bedside.

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THE PROJECT

The AONE Institute studied CNO turnover and its impact on the nursing workforce and the quality of hospital care through online surveys of CNOs, nurses and mid-level nurse managers and telephone interviews with CNOs and health care executive recruiters.

The project team conducted the study in three phases from September 2005 to April 2006:

  • An online survey of current, interim/acting and past CNOs designed to address the CNO's role, current or prior experiences with turnover and retention issues. The team mailed a notice about the survey to about 6,000 hospital and health system CNOs in the United States; 634 CNOs completed the survey.
  • Telephone interviews with CNOs and health care executive recruiters seeking further details on these issues. Twenty-six CNOs and five recruiters participated in the telephone interviews. The team used e-mail to invite recruiters in firms that recruit CNOs to participate.
  • An online survey of nurse managers and staff nurses exploring the impact of CNO turnover on their work and on patient care. The team mailed the request for staff/nurse manager participation to the original 6,000 CNOs, who passed it on to nurse managers and staff nurses in their organizations. This generated 1,277 responses.

Two consultants from the University of North Carolina at Chapel Hill faculty assisted the project team in designing and conducting the survey, under a subcontract: Donna S. Havens, Ph.D., R.N., professor of nursing, and Cheryl B. Jones, Ph.D., R.N., associate professor of nursing.

The project team presented preliminary survey data at the 2006 American Organization of Nurse Executives annual meeting in Orlando, Fla., in April and at the 2006 Institute for Nursing Healthcare Leadership conference in Boston in June.

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FINDINGS

The project team reported the following findings in a report to RWJF:

  • About 39 percent of CNOs had left a CNO position. Of these, 77 percent left voluntarily and 23 percent left involuntarily. The top five voluntary reasons for leaving were:
    • To take another CNO position: 50 percent.
    • For career advancement or development opportunities: 30 percent.
    • Conflicts with the CEO: 26 percent.
    • Job dissatisfaction: 21 percent.
    • Family/personal reasons: 20 percent.

      (The percentages add up to more than 77 percent because some CNOs selected multiple answers.)
    • Involuntary reasons for leaving were:
      • Being asked to resign: 8 percent.
      • Being terminated: 4 percent.
      • Other reasons such as mergers, downsizing, restructuring and/or hospital closure: 9 percent.
      • Family/personal reasons: 2 percent.
    CNOs who have been involuntarily terminated said they would have found counseling and support helpful.
  • About 62 percent of CNO's anticipate changing jobs in less than five years. Reasons for potential departure from their current jobs were:
    • Promotion or advancement: 28 percent.
    • Achieve work/life balance: 28 percent.
    • Retirement: 27 percent.
    • Take another CNO position: 20 percent.
    • Take a chief operating officer or chief executive officer (CEO) position: 20 percent.
    • Personal/family reasons: 18 percent.
    • Lack of power: 18 percent.
    (The percentages add up to more than 62 percent because some CNOs selected multiple answers.)
  • CNOs, nurses and nurse managers identified good relationships with the CEO and senior management team as crucial for CNO retention, recruitment and overall success in the CNO role:
    • 79 percent of CNOs reported very good or excellent relationships with CEOs.
    • 87 percent of CNOs reported very good or excellent relationships with senior organizational leaders.
  • Almost half (48 percent) of the nurses and nurse managers were affected by the departure of a CNO:
    • About 36 percent felt the nursing division had lost "an important friend and advocate."
    • About 12 percent said they had lost "a personal friend and co-worker."
  • 80 percent of nurses and nurse managers reported that the quality of hospital care stayed about the same when a CNO departed; about 14 percent said quality deteriorated and 7 percent said quality improved.
  • Health care executive recruiters said that CNOs need to develop strong financial skills to compete in the current market and to be successful in the role of CNO.
  • CNOs, nurses and nurse managers also identified the need to develop the financial skills of CNOs. Suggestions included educating, preparing and mentoring "the next generation of CNOs" in finance so that they can "compete on the same level" as other senior managers.
  • Succession planning — identifying and guiding nurses and nurse managers with the potential to become CNOs — is a key imperative.

Limitations

  • The voluntary participation of respondents may have produced different findings from those from a true random sample. The researchers worked diligently, however, to get the most representative sample possible by sending out several e-mail reminders.

Recommendations

The project team reported the following recommendation in a report to RWJF.

  • The American Organization of Nurse Executives or other researchers should replicate the survey in future years to establish trends in CNO turnover and retention. Since this was the first survey on this subject, findings would serve as a benchmark or template.

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LESSONS LEARNED

  1. Build extra time into the schedule for projects that require institutional review board (IRB) approval. This project was delayed twice by the need to obtain IRB approvals from the University of North Carolina at Chapel Hill. The university required the project director to take an online course to be certified and had to approve the survey itself. (Project Director)
  2. Have technical support available for projects that use electronic surveys. Electronic surveys are still fairly new as a research methodology. An information technology specialist at the American Organization of Nurse Executives provided prompt technical support to survey participants. (Project Director)

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AFTER THE GRANT

As of October 2006, the project team was writing articles on the survey for placement in health care journals.

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GRANT DETAILS & CONTACT INFORMATION

Project

Studying Retention and Turnover of Chief Nursing Officers

Grantee

Health Research and Educational Trust (Chicago,  IL)

  • Amount: $ 46,200
    Dates: December 2004 to June 2006
    ID#:  052201

Contact

Pamela Thompson, M.S., R.N.
(202) 626-2240
pthompson@aha.org

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Report prepared by: Paul Jablow
Reviewed by: Lori De Milto
Reviewed by: Molly McKaughan
Program Officer: Susan B. Hassmiller

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