Is it time for more nurse CEOs?

With nearly one-third of registered nurses considering leaving their current roles amid historic workforce shortages, healthcare executives nationwide are scrambling to better understand and meet nurses' needs. This task may come easier for hospital and health system CEOs with hands-on nursing experience, but so-called "nurse CEOs" are few and far between. 

"We're still unicorns in healthcare administration," said Nancy Howell Agee, MSN, BSN, CEO of Roanoke, Va.-based ​​Carilion Clinic. 

Ms. Agee started her career as a surgical nurse at Carilion Clinic and became CEO in 2011. Since then, Ms. Agee said she has not seen an increase in the number of healthcare CEOs with nursing backgrounds.

"It may even be fewer … because of mergers and acquisitions and the changing industry," she said, noting that nurse CEOs have historically run smaller healthcare facilities. 

The true proportion of nurses who are healthcare CEOs is unclear due to a lack of data. The American Organization for Nursing Leadership and the American College of Healthcare Executives told Becker's they do not track the number of hospital and health system CEOs with nursing backgrounds. An analysis of the CEOs leading U.S. News & World Report's top 20 hospitals reveal just two have nursing backgrounds: Johnese Spisso, RN, president of UCLA Health and CEO of the UCLA Hospital System; and Regina Cunningham, PhD, RN, CEO of the Hospital of the University of Pennsylvania in Philadelphia.

Becker's spoke with three nursing leaders to understand why there are not more nurses in CEO roles and whether CEOs with nursing backgrounds could bring a competitive advantage to health systems aiming to create a better environment for these clinicians. 

What's holding nurses back

Nurse CEOs' scarcity is likely linked to broader issues surrounding female representation in healthcare leadership, Ms. Agee said. Although federal data shows 76 percent of the healthcare workforce and 87 percent of nurses are female, women represent just 15 percent of industry CEOs.

Nurses also do not have much representation on hospital and health system boards, which appoint CEOs. Data from the American Hospital Association in 2017, for example, showed just 5 percent of U.S. hospitals had a nurse as a trustee or serving on a board. 

"Nurses are not always given a seat at the table," Loressa Cole, DNP, RN, the American Nurses Association Enterprise CEO, told Becker's

Dr. Cole said the ANA has sifted through data to look at how the number of nurses serving on hospital or system boards has changed over the years. 

"We've really not made much progress in that regard, even though the American Hospital Association itself says that there is significant value to having nurses on boards," she said. 

Nurses' absence on boards means leadership might not fully grasp the skill set or value a nurse leader could bring to the CEO role, as nurse members would be best suited to communicate that. 

"A lot of boards are filled with people with strong financial backgrounds and strategic backgrounds, and it doesn't seem natural that the boards begin to look for a nurse as a CEO," Ms. Agee said. 

Additionally, the healthcare industry must do away with the assumption that "strong nursing leaders really have one track, which inevitably leads to being a chief nursing officer," Dr. Cole said. 

"I think it's really up to seasoned nurse leaders to not only demonstrate the talent, skills and aptitude, but to really dispel myths that there is only one lane into the C-suite for nurses in this country," she said. 

Most nurses likely don't consider themselves fit to be a CEO and may rule it out early on when thinking about paths to leadership. Part of that stems from "mystique" surrounding the role, as well as nurses' focus on their communication and clinical care skills. 

"I think nurses go into nursing because of their passion and their concern and care for patients and improving the health of their communities, which of course is the same thing that a CEO would want. But most don't see themselves in that role," Ms. Agee said. "There's a sense that the skills you need — whether they are financial skills or data analytics, political skills, etc. — all of that is not exactly how nurses have traditionally viewed their talents."

But seasoned nurse leaders already demonstrate each of these skills. 

The value of nurse CEOs

Working directly at the bedside provides nurses with unique experiences not shared by other executives, according to Dr. Cole. These experiences, in turn, translate to unmatched leadership skills. 

"Year after year, the Gallup organization has determined nurses are the most trusted profession in the U.S., and really that comes from having super honed listening skills," Dr. Cole said. "We are also accustomed to working well with teams and have innate talent to lead by example and to bring strong [human resources] skills to the table. Nurses simply know how to work with other people."

Dr. Cole also said nurse leaders are often tasked with managing "extremely large" budgets, which in turn allows them to understand inefficiencies.

"Typically, senior nursing leaders, nurse executives, are overseeing at least half of the workforce, so they do understand budgeting and financial impact of inefficiencies," Dr. Cole said. "They understand how variation in processes ultimately breaks down the system and ends up costing money, and they absolutely understand customer dissatisfaction and what is satisfying to patients and families we serve."

UCLA Health's Johnese Spisso, RN, began her career as a registered nurse in a critical care unit. Ms. Spisso said she believes her background is part of the reason why she was selected for her current position. 

"People felt that I understood the needs of patients and families but also the needs of the staff and everyone on the team, and a lot of that came from working as a registered nurse earlier in my career," she said. 

"An understanding of not only the role of nursing, but the role of respiratory therapies, social work, pharmacy, nutrition, physicians is really pivotal to delivering best care and is really how those teams work together," Ms. Spisso added. "And I think having experience on the front lines of nursing and also coming up through the ranks in nursing really gave me broader visibility to that."

Ms. Agee said she believes there is an "enormous benefit" to executives having nursing backgrounds and that she is a better CEO because she was a part of this community of caregivers.

"It's important for a CEO to have that deep understanding and appreciation for that very human work of healthcare," Ms. Agee said. "What I call the magic or sacred moment between a caregiver and a patient. The nurse brings that to their core." 

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