The Real Worries a CNO Loses Sleep Over

Posted by RiAnn Bradshaw on 2/11/21 3:52 PM

Topics: Health Care Staffing, Well-Being

Our team scoured the internet, pooled experience, called upon all available resources. The results of that effort is this collection of real worries that keep a Chief Nursing Officer or Nurse Manager awake at night.

Instead of just listing a slew of problems, we want to pose ideas and solutions. Nothing comes from silence! We hope you find this article helpful and encourage feedback if there are edits or additions that should be made.


The turnover in leadership is picking up speed.

Hospital CEO turnover alone holds steady at ~18% annually, per the American College of Healthcare Executives. That means that almost one in five CEOs will change their seats this year. Running a high-volume operation is demanding, add the onboarding necessity of a new-hire CEO or any executive leader and your company is already looking at six months of relationship building, integrating into the role, familiarizing your new leadership with resources, and more.

Imagine if that was happening every other year? It would be absolutely chaotic and places organizational leadership in inconsistent circumstances. As a healthcare provider, this is not a welcomed factor. Chief Nursing Officers and unit managers have minimal immediate impact to address this problem, but there are a few things they can do over time to help lessen the turmoil and navigate leadership turnover successfully.

  • Document your role and keep a resource pool of common Q&As that higher-ups request. Yes your role is incredibly important, but no one really knows how important until it's not being done anymore. Skip that headache with due diligence and anticipating new leadership's questions or needs.
  • Keep a running list of efficient, effective and experienced FULL-TIME floor staff. Not only will you be able to help disseminate information quickly, but if you're not available to answer a question you do know who would be (probably).
  • If your unit regularly sees contingent labor and temporary nurses, get their information and keep it on file for future needs. You know when you will eventually need a per diem filled and your Central Staffing Office may be taking longer than ideal. Being this prepared will save your department revenue over time and demonstrate your managerial value.


What about nurse leadership specifically?

Highly successful CNOs have contingency plans, succession planning, build effective teams, and often mentor their competent nurses well in advance of even needing to place them in a leadership position.

Identify "rising stars" in your organization, or incentivize managers at different levels to start recognizing these key players. A few things that exclaim "future leader" include the commonplace but impressive feats of strength you only hear about around the floor.

  • If their transportation is disrupted somehow, they are able to plan well enough around the variable to make it to work the same or following day.
  • They keep a proactive and problem-solving mindset in the face of adversity. Note that this does not mean they don't react to stress, it simply means they function under stress and often thrive.
  • They are active in the organization whether it is demonstrated by extra shifts, mentorship program involvement, or leadership development activities.

Succession planning can feel similar to a mentorship program but differs starkly in its procedural importance for an organizations growth, like when leaders are promoted or leave the organization. Succession planning could include coaching, providing resources and learning opportunities specifically related to preparation for promotion, or involve shadowing in various areas or transfers to different departments.

Work with your organizations human resources department to set a clear and achievable standard for nurse leadership. It will improve your work environment and also demonstrate your own talents, especially to a new CEO.


Hospital budgets get tighter due in part to declining reimbursements.

We all like being frugal but is healthcare really the place to pinch pennies? Chief Nursing Officers have to succeed with tighter and tighter budgets and a shortage of viable staff. Though this feels somewhat normal for an employer or manager, it's not quite the same in healthcare. Hospitals often leverage a Managed Service Provider (MSP) to help fill these staffing gaps and remove some of the burden from the CNO or hiring managers. 

An effective way to recover lost revenue as a CNO is to keep a very very sharp eye on your contingent labor usage. As CNO, you're likely removed from the contingent workforce management side of staffing operations. Potentially you're free to send a request to a central staffing office in your health system and almost seamlessly a temporary nurse will appear for that necessary shift.

How often if this occurring? Do you know if there was a local option from a previous staffing arrangement? Was your float pool appropriately consulted? 

As a Chief Nursing Officer or hiring manager, those are the questions you would ideally have answers to off the cuff. The effect becomes more apparent over time; this is a massive drain on health system resources, CNOs and nursing teams.

Learn more about the hidden cost of MSPs and staffing agency placements for health systems and hospitals.


Inconsistent or inexperienced nurse leadership on night shifts can be chaotic.

Your tenured nurses and team members gained flexibility in their schedules. Of course you want to uphold that benefit and bolster retention of your qualified nurses. However, a direct result is that night shifts do not always have a marked leader to rely on. Less experienced nurses are usually assigned to night shifts and need that experienced floor manager. How do you balance these two factors as a CNO or human resource team?

Set a schedule for a term and make sure there is experienced leadership on shifts with less experienced teams. This is commonly seen in emergency department operation centers and has demonstrated success over decades.

For example, at the start of each six-month term PTO requests are to be submitted for the following six-month term. Seniority can be used to leverage priority of request. For unscheduled time, first come first serve can be a good way to handle priority of the requests as well.

This provides human resource and scheduling teams with a runway to properly balance assignments for each unit and shift. Implementing a policy like this does require planning and effective communication yet it is worth every moment of preparation. Your employees will appreciate the transparency in policy and your night teams will feel better supported, likely reducing patient crises in turn.


New graduate nurses dominate the candidate pipelines.

Sparing all of our readers (and writers) the use of the M word, more than four million new-grad healthcare providers will enter the workforce over the next decade.

Remember your first job? You probably felt a little green.

Remember your first overnight ER shift? Likely hard to forget...



CNOs will be expected to balance the need for tenured staff on night shifts as mentioned above, while onboarding and training new-grads to get them up to speed on the practice instead of only the theory behind health care. To help address the newbie stress on overnight shifts, consider the above advice about experienced leaders for those times and also the below.

  1. Incentivize gaining experience within, and loyalty to, the organization.
  2. Regularly debrief nurses after critical occurrences. Make them feel human again, we all make mistakes or misunderstand but not everyone knows the feeling of having someone's live in their hands quite as well as a peer in this scenario.
  3. Provide experiential cheat sheets. You've seen that before? Write it down and make it available for your team because chances are it will happen again.


Nurse recruitment is already tricky but add retention to the mix.

The history of nurse staffing within health systems and hospitals has brought the modern situation to a point of confusion and perceived lack of competent candidates. Without breaking into that topic just yet, bear in mind that health systems and hospitals total hospital bed counts have reduced by nearly 38% since 1975 (Statista) (

The demand has grown. The provisional resources have reduced. The population increases. Education in medicine is arduous and expensive. Over the course of time is this holding true or just an employment nuance?

  • The total US population is estimated at 331 million individuals (Worldometers).
  • Population increased by roughly 100.2 million since 1975.
  • Available hospital beds reduced by roughly 38% (546,269) since 1975.
  • There are over 3.8 million RNs nationwide (AACN).
  • There are over 870k practicing MDs nationwide (Statista).
  • On average, 92% of people do not visit the hospital during a 12-month span.

The shortage is simply perceived. What could the solution be then? Why is it happening?

Well, why does anyone choose to work elsewhere? The work environment needs to improve and it always begins from within, with leadership, and needs positive reinforcement to ripple through the organization.

As a nurse or healthcare provider you already know you got into this industry to help people just as much as any other reason. Your peers and colleagues likely feel similar to you on that stance. When nurses see value in what they do on the day-to-day, feel good about who they work with and who they work for, engagement, retention, and quality of care increase dramatically.

I think what hospital executives need to understand is that the generation of nurses that have been coming out [of nursing school] over the last five to seven years—and the ones that will be coming out over the next five to seven—they want something different than what the baby boomers wanted.

- Paula McKinney



The quality of patient care relies heavily on the team present at the time of administration.

The present team during any circumstance could vary in skillsets that are less tangible than a competency test would show. things like technological aptitude, cultural awareness and professional communication are not evenly distributed in any workforce.

Innovative technology will spotlight areas to improve in industry workflows like contingent workforce management, float pool management, unit budgeting, and other organizational processes. Productivity is a measurement seldom quantified without dollar signs. However, a leader does not know what they do not know. Put your money where your monitors are and learn more about where your resources are really drained or underutilized. Things like HRIS systems and VMS tools will return your investment of time and budget, exponentially.

Increasing awareness of cultural differences and how it can be applied to improving patient care is seldom spoken about in popular discussion, often overshadowed by more blanketing topics like budget restraints and provider turnover. Don't be too loose in your interpretation of competent when it comes to culture and communication. Nurses already know, much of the job is effective communication. Culturally aware patient care can be bundled with mentoring and leadership development opportunities and get your organization on a trajectory to be the best place for providers to work in years to come.

Effective communication matters in all industries, all relationships, all scenarios. We do not discuss this topic enough (coincidence?) and should always be working on improving our communication interpersonally and professionally. To summarize and cite a recent study on the matter:

The link between miscommunication and poor patient outcomes has been well documented. To understand the current state of knowledge regarding interprofessional communication, an integrative review was performed. The review suggested that nurses and physicians are trained differently and they exhibit differences in communication styles. The distinct frustrations that nurses and physicians expressed with each other were discussed. Egos, lack of confidence, lack of organization and structural hierarchies hindered relationships and communications. Research suggested that training programs with the use of standardized tools and simulation are effective in improving interprofessional communication skills. Recommendations include education beyond communication techniques to address the broader related constructs of patient safety, valuing diversity, team science, and cultural humility. Future directions in education are to add courses in patient safety to the curriculum, use handover tools that are interprofessional in nature, practice in simulation hospitals for training, and use virtual simulation to unite the professions.




Our team sincerely hopes that this information was found helpful for CNOs, human resource teams and hiring managers for health systems and hospitals. Solutions for upper-middle management gain importance as our population grows and technology outpaces healthcare implementation.  You're appreciated. You're doing great out there.

Let our marketing team know if there are additional topics you'd like to see expanded on.

Source 1. Source 2. Source 3. Source 4. Source 5. Source 6.

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