Chief nursing officers (CNOs), who lost some clout in hospital reorganizations during the '90s, are again immersing themselves in the leadership of healthcare organizations throughout the country.

"Because of issues in the industry with recruitment and retention and some practice issues, organizations feel there needs to be nursing leadership at the executive table to move nursing forward," says Susan Hallick, CNO for Geisinger Health System in Danville, Pennsylvania. "It makes a statement about the importance of nursing in the system."

CNOs typically report directly to a facility's chief executive officer or chief operating officer and oversee hundreds of nurses and nurse managers. A CNO's duties are vast and can include strategic planning, reporting to a board of directors, helping develop and oversee the annual budget, handling staff and patient issues, checking on new payroll systems and making clinical rounds.

Laura Caramanica, vice president of nursing for Hartford Hospital in Connecticut, says the nurse executive's unique task is to "stay close to the needs of patients and staff, and help the other members of the executive team and board understand the implications of their decisions."

Ascending to CNO

Mary McFadden is the assistant administrator for patient-care services at Kaiser Permanente's Sacramento Medical Center in California. She started her career trajectory toward a CNO post three years into her nursing career and spent 17 years overseeing a variety of departments and patient populations before moving into her first CNO job. She counts her broad experience as an asset.

"You need to develop a skill and knowledge base that encompasses several different patient populations," McFadden says. "Having done that was helpful to me, and I think it would be for anyone who wants to assume the role of nurse executive."

Ascending to a CNO position requires eight to 10 years as a registered nurse, with several years spent in a managerial role, such as department supervisor or manager. While CNOs typically have a master's degree in nursing administration, healthcare organizational development or business, business degrees are fast becoming the trend as potential CNOs seek a well-rounded background.

For instance, Hallick has a master's in healthcare administration, McFadden has a master's in nursing administration, and Caramanica has a PhD with a concentration in management.

Nurse-Executive Material

Important traits for CNOs are flexibility, strong collaboration skills and the ability to remain highly organized in a fast-paced job. Hours are long and varied and include evenings, weekends and holidays.

"Flexibility and adaptability to a rapidly changing environment are key," McFadden says. "There are days when there are significant competing priorities. The challenge is to be able to multitask in a confident manner, knowing which priorities have the top priority."

Though the everyday tasks of a CNO are important, Hallick says nurse executives must remain creative and forward-thinking when it comes to recruitment, retention and employee morale.

"You get so caught up in the day-to-day kinds of things [that] you have to bring yourself out of that and think future, think vision," she says.

Understanding the Numbers

Business acumen is also essential to being a CNO. At many healthcare facilities, such as Kaiser Permanente, CNOs oversee the largest chunk of a facility's annual budget.

Hallick works with Geisinger Health's chief financial officer, chief administrative officer and chief medical officer to develop and meet parts of Geisinger's budget, which she cites as a favorite aspect of her job.

"That involvement with my team allows me to help nurses understand that there's a business end to this," Hallick says. "The ability to match giving good clinical care and having good outcomes with making sure we're financially sound has been a good professional opportunity."

Hallick works hard in her leadership role. She typically puts in 12-hour days and occasionally comes to the facility on weekends and about once a month at 3 a.m. or 4 a.m. to interact with staff on the night shift.

"I believe that the opportunity for CNOs is great," she says. "The role is challenging, but there's a lot of impact that CNOs have with the right structure and with the right support. I think it's a great position."