Nurse managers are the 'CEOs' of their patient care area, and it's the CNO's job to support them, according to this nurse leader.
It's a new year, and people all around the world are setting new goals and resolutions for themselves, including CNOs.
In 2025, CNOs and other nurse leaders will have to keep track of many different trends and challenges, including the ones facing a critical part of the workforce: nurse managers.
Nurse managers are vital to the success of a health system. According to the Trends and Innovations Nurse Manager Retention report that was released by the American Organization of Nursing Leadership (AONL) and Laudio in the fall of 2024, nurse manager retention is key to building a sustainable and high-performing healthcare setting.
However, the report says that nurse manager turnover is highest within the first four years of leadership, and according to Robyn Begley, chief executive officer of AONL, and senior vice president and chief nursing officer at the American Hospital Association (AHA), this is due to very high levels of stress and burnout.
"As a former nurse manager earlier in my career," Begley said, "I can tell you it was the most challenging role that I've had in nursing leadership in my entire career."
Nurse manager challenges
Nurse managers are responsible for patient care, their nurses, 24/7 staffing for their units, budgeting, and compliance with regulations. Begley explained that it's not easy for nurses to move to a nurse manager role, and it should require formal training in leadership, management, and administrative skills.
"They are really the CEOs of their patient care area," Begley said. "Transitioning from a clinical role to a managerial role requires different competencies."
Nurse managers work long hours and have to constantly be available in case something goes wrong, and this can have a large impact on their personal lives and wellbeing.
“Hospitals and healthcare settings are very frequently 24/7 operations," Begley said. "Work-life balance gets a lot of attention, and this really is one of those areas [where] it's challenging for a nurse manager, and this can strain their wellbeing."
Organizational culture also has a large impact on nurse managers, and, according to Begley, it can influence a nurse manager's job satisfaction. CNOs need to make sure that support systems are available.
"Some new managers may feel isolated or perhaps unsupported," Begley said, "finding it difficult to navigate their new responsibilities and feel confident in their roles, especially in those first few years."
The nurse manager's role may also be ambiguous, so Begley recommends clarifying their responsibilities as best as possible to avoid confusion and lack of direction.
"Many times, if a new initiative comes into play, who is left to actually make sure that it gets implemented and outcomes are monitored and measured?" Begley said, "it's the nurse manager."
Nurse manager turnover also greatly affects the rest of the staff. Begley explained that strong, effective communication and trust takes time to build, and frequent turnover disrupts that process and makes it difficult for staff to develop meaningful relationships with their managers.
"Frequent changes in management can create a sense of uncertainty and instability among those units that have frequent turnover," Begley said. "This can lead to decreased morale and job satisfactions, as employees, the nurses, the nursing assistants, and the clerical support on those units may feel that their work environment is unpredictable."
Improving nurse manager retention
Begley had several tips for CNOs who want to improve their nurse manager retention. As CNOs continue to build an engaging and psychologically safe environment for nurses, they must also think about nurse managers and how they can feel safe speaking up, surfacing concerns, and potentially disagreeing without negative repercussions.
"They understand what it's like on the front line and they have to feel free to be able to communicate that back to executive nursing leadership," Begley said. "They have to feel like they can tell it like it is and not sugarcoat some of the messaging that they really do need to communicate to their leadership team."
Additionally, Begley suggested that CNOs allocate resources and advocate for the funding to provide formal training to their nurses who are aspiring to become managers or leaders.
"It takes continuing leadership development and education because we know there's always something new to learn and things are changing in healthcare very rapidly," Begley said.
CNOs also need to be showing up for their nurse managers in tangible ways.
"Nurse managers told us how important it is to actually see their leadership and to have communication and conversations with them," Begley said. "Not just fly by rounds where leaders will stroll through a unit, say hi, try to check in with the staff quickly, but really scheduled time for managers to be able to engage in dialogue is what is required."
Meeting nurse manager expectations
In the report, nurse managers had four priorities that they want CNOs and other nurse leaders to focus on: ensuring a healthy work environment, promoting leadership development, identifying new leaders early, and addressing role complexity.
Begley emphasized the necessity of succession planning for upper management and for executive management, and that there needs to be planning for every level of leadership.
"That involves a formal plan, a succession planning framework, that includes purpose, level, assessment, and nurturing," Begley said. "We know with the baby boomer retirements that we are creating space in leadership in nursing, as well as in many other professions."
The career trajectory of many nurses nowadays is also vastly different than what it used to be, Begley explained.
"There are some young up-and-comers who are very willing and able to take on more, to learn and aspire to be leaders," Begley said, "so these organizations need to do a deep dive and do that assessment and really figure out what their staff nurses desire to do in the future."
Health systems need to provide exposure to what nurses at different levels do, and provide formal education and leadership development, according to Begley.
"It's wonderful if nurses decide to stay on the clinical track and become more proficient in a specialty area, or go into a clinical track for advanced education," Begley said, "but there are also nurses that want to pursue nursing leadership as their specialty, and they also require a career plan."
In terms of role complexity, Begley said AONL is focusing not only on span of control, but also on what leaders can do to take some of the burden away from the nurse manager.
"Clerical work could be done by an assistant, by someone who is perhaps not a nursing leader or a nurse manager, but can do things like scheduling, managing logistics of their unit, [or] supplies," Begley said. "It's so complicated when we look at what [nurse managers] are actually accountable for."
Begley also emphasized the issue of having four generations in the workforce. One solution is technology and innovation, and having nurse leaders at all levels embracing technology and learning how to use it.
"These are skills that perhaps a decade ago or more, nurses weren't innately exposed to in their education," Begley said, "but we know now that technology and innovation is truly the key to the future of transforming healthcare and helping our communities become healthier."
To read more about AONL's previous spring report on nurse manager span of control, click here.
Researchers found that most health systems following the CMS Acute Hospital Care at Home model are large urban hospitals, and said the current model may not be sustainable for small or rural hospitals.
A new study of the Hospital at Home strategy questions whether it can stand up in rural areas and small hospitals, key markets for the innovative program’s growth and sustainability.
In a December 23 study posted in JAMA, researchers from UCLA and the University of Pennsylvania say almost all of the healthcare organizations participating in the Centers for Medicare & Medicaid Services (CMS) Acute Hospital Care at Home (AHCAH) program are large, urban, not-for-profit and academic hospitals.
As of December 2024, 373 hospitals across 139 health systems in 39 states are following that CMS model, which includes a waiver enacted in 2020 to help participating hospitals receive Medicare reimbursement. The waiver was recently extended to March 31, 2025, and with CMS hinting that it will no longer grant extensions, supporters are lobbying Congress to make it permanent.
The implications of this latest study are that only large, well-resourced health systems can sustain a Hospital at Home program, leaving a significant percentage of the nation’s health systems and hospitals out in the cold. Yet advocates say this strategy, while complex, can save money and resources and improve clinical outcomes, all key metrics for any type of hospital.
“If CMS’ goal is to continue to expand hospital-at-home, these findings suggest that different incentives or outreach may be needed for smaller, rural, and non-teaching hospitals,” Hasham Zikry, MD, MS, an emergency medicine physician and clinical research fellow at UCLA Health and lead author of the study, said in a press release.
(One notable exception is Sanford Health, which launched its CMS-approved AHCAH program in November 2024 targeting patients in rural communities around Fargo, North Dakota. The health system is currently targeting an annual daily census of five patients and hopes to bring that number up to 12 soon.)
Zikry and his fellow researchers, David Schriger, MD, of UCLA Health and Austin Kilaru, MD, MSHP, of the University of Pennsylvania’s Perelman School of Medicine, also cite two familiar criticisms of the Hospital at Home movement: That these programs haven’t yet proven their value, and that they don’t take into account the pressure put on patients and their caregivers at home.
“Are family members of these patients acting as unpaid caregivers during these admissions?” Zikry asked in the press release. “Could these patients do just as well in other care settings? Do patients actually prefer to be at home? And are health systems leveraging this program equitably?”
In addition, he said: “Resources are being poured into these programs around the country, yet we still don’t have a comprehensive understanding of how the programs are functioning on the ground.”
Many expect the Hospital at Home strategy to take a hit if Congress declines to extend the CMS waiver or make it permanent. Without Medicare reimbursement and a relaxation of certain telehealth rules, some health systems may end or cut back their programs.
That said, supporters are arguing for at least another extension so that participating health systems can gather the data needed to prove the concept’s value. The prevailing opinion among both supporters and critics is that the strategy needs more time to gather data to prove value.
Virtual nursing must be additive, not a replacement, according to this nurse leader.
HealthLeaders spoke to Katie Boston-Leary, senior vice president of equity and engagement at the American Nurses Association (ANA), about several pressing concerns for CNOs, as well as nursing trends, like virtual nursing, that will continue into the new year. Tune in to hear her insights.
The HealthLeaders Exchange is an exclusive, executive community for sharing ideas, solutions, and insights.
With its Digital Health Summit, the annual Consumer Electronics Show is giving healthcare leaders a look at the potential for truly integrated care.
As CES 2025 kicks off this week in Las Vegas, healthcare’s innovation and transformation leaders are keeping an eye on the Consumer Technology Association’s (CTA’s) Digital Health Summit, as well as the various consumer-facing technologies, tools, and toys that could play a role in the health system of the future.
Healthcare has long claimed a part of the CES experience, starting with connected devices and apps designed to help consumers manage their health. Over the past several years, though, healthcare executives have joined the party, looking for tools and strategies to bridge the gap between the consumer and the patient.
Rene Quashie, CTA’s Vice President of Digital Health, says the event gives healthcare leaders an opportunity “to explore the future of health tech in the context of a broader, interconnected ecosystem.”
“Unlike traditional health conferences, CES brings together the full spectrum of technology innovators across industries, creating an environment where healthcare solutions are discussed alongside advancements in AI, robotics, IoT, and beyond,” he said in an e-mail to HealthLeaders. “This convergence fuels cross-industry collaboration, helping healthcare leaders identify transformative technologies and adapt them to meet the needs of consumers, clinicians, and payers.”
That integration should continue as health systems and hospitals push more services out of clinical settings and into the home, and as care providers develop programs to track their patients at home and manage care remotely. Strategies like remote patient monitoring (RPM) and Hospital at Home will rely more on consumer-friendly devices as that scale up and build sustainability.
Against that backdrop, there are opportunities for healthcare throughout the CES exhibit halls, which span both the Las Vegas Convention Center and the Venetian Expo. The smart home concept is an intriguing venue, with AI-enabled devices, sensors and appliances that can be used to monitor consumer activity and health, even diet, sleep, behavioral health and bathroom activity. Automobile manufacturers are including health apps and sensors in their new models, and even the popular gaming area includes games and gaming platforms that can be used for healthcare.
Quashie says the theme for healthcare-related events and vendors at CES this year is “the future of health,” with topics including AI, digital therapeutics, genomics, wearables, women’s health and workforce issues.
Will leaders get the answers they need from CES to advance their orginizations? I'll be there to report.
Here's what CNOs were reading in 2024 on HealthLeaders.
2024 was quite the year for healthcare.
This year, CNOs and other nurse leaders faced a wide array of challenges, from expanding the nursing workforce through recruitment and retention, to tackling new technologies like AI and virtual nursing, and to addressing nurse burnout and wellbeing. Many of these issues are expected to continue, while more will appear on the horizon in the new year.
Here are the top five nursing stories from HealthLeaders in 2024.
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Nursing Needs a Reality Check: Changing Expectations - Read here
You Won't Need As Many Nurses. Sooner Than You Think. - Read here
HealthLeaders’ most-read stories of the past year highlighted an interest in virtual care and care management, especially when connected to CMS coverage
The growing market for virtual care dominated HealthLeaders’ most-read innovation stories of 2024.
Coming out of the COVID-19 pandemic, healthcare providers were fighting for the attention of empowered patients/consumers and facing competition from employers looking to control health plan costs and disruptors eyeing the convenient care market. The resulting battle for primary care saw a proliferation of virtual care platforms, giving patients access to primary care at the time and place of their choosing.
2024 saw an expansion of that strategy, with virtual care platforms for specialist consults, chronic care management, remote patient monitoring and other services.
The top story for the past year focused on one of the biggest disruptors in that market, Amazon, which launched Health Condition Programs in January. The online platform matches consumers to relevant health and wellness companies based on their browsing and shopping habits, enabling consumers to create managed care plans based on their health concerns and health plan coverage.
“Amazon wants to make it easier for people to get and stay healthy, and part of that is making it easier to discover the products, services, and professionals that can help them do that,” Aaron Martin, Amazon’s vice president, said in a press release issued by Omada Health, a digital health company that is partnering with Amazon to offer diabetes prevention and care and hypertension care services through the new platform. “Many aren’t aware of the healthcare benefits they are eligible for, that are typically no cost or subsidized by their employer or insurance plan. When customers are shopping for health-related products on Amazon, we can surface these benefits to provide even more support in improving their health, at no additional cost.”
Healthcare providers are bullish on care management as well, and they want to use virtual care and digital health to create those services for their patients. The traditional sticking point has been reimbursement: providers won’t fully embrace new technology unless they’re paid to use it.
The second-most popular story this year was the Centers for Medicare & Medicaid Services’ (CMS) new program to support providers using virtual care and digital health to create value-based care programs. The Advanced Primary Care Management (APCM) model, with HCPCS codes included in the 2025 Physician Fee Schedule, incentivizes clinicians to use technology to create care management pathways around their patients, a key strategy on the journey to value-based care.
“While these new codes come with a number of administrative requirements, the APCM codes provide additional opportunities for practitioners to collect reimbursement for care management services, some of which they may already performing,” Alexandra Shalom, senior counsel with the Foley & Lardner law firm, said in a November blog. “HHS has long noted that effective primary care services and relationships are critical to improve health equity and access to care and as early as 2014, CMS recognized care management as a key component of primary care. As such, CMS’s goal in offering these codes is that it will allow practices to enhance or expand their care management services, which in turn will improve population-level mortality and reduce disparities.”
The third most-read story veered off in a different direction, though still focusing on the idea that providers are using virtual care and digital health to beef up their patient engagement efforts. A panel session at the HIMSS24 conference and exhibition this past March centered on how smaller health systems and hospitals, struggling to make ends meet and faced with competition, are changing their business model to focus on care management and preventive care, rather than ‘sick care.’
“A great deal of our future is in the outpatient side,” Tressa Springman, SVP and chief information and digital officer at LifeBridge Health, a five-hospital system based in Maryland, said during a panel session.
She noted that more than 50% of the health system’s quality-based reimbursement score for the state is focused on the patient experience, making that more important than actual clinical care. So they’re now setting their sights on access, convenience, and outpatient interactions.
“We’re really focusing on the community,” she said.
The draft and final PFS also gave advocates of digital therapeutics some good news: New HCPCS codes that will enable providers to seek reimbursement for some behavioral health treatments that use FDA-approved devices.
On the other hand, CMS did include some small improvements in telehealth coverage, but also said it wouldn’t extend most pandemic-era waivers to telehealth coverage and access. The news stunned telehealth advocates and led to coordinated lobbying efforts to have Congress extend those waivers. That lobbying will continue into 2025, as Congress only extended those waivers for three months in its year-end, stopgap funding bill.
The fifth most-read story of 2024 centers on perhaps the biggest lesson learned this year in healthcare innovation: Disrupting the status quo to achieve true transformation is hard. This past May Dollar General, the nation’s largest retailer by number of stores, announced that it was ending a two-year partnership with digital health provider DocGo.
The news wasn’t exactly, well, new. Walmart, Walgreens and CVS Health had all recently rolled back their primary and virtual care ambitions, highlighting the challenges that the retail and pharmacy chains were having in cracking the healthcare market. The lesson to be learned, perhaps, is that healthcare isn’t an easy nut to crack, and while new ideas from outside the industry may look great on paper, they aren’t scalable or sustainable.
Virtual nursing is so transformative that we are near the first generation of nurses who may never touch the patient.
Editor's Note: This is an excerpt from a larger cover story, which can be found here.
2024 was a year for great innovation.
Health systems made great strides toward implementing new technologies into workflows, including AI, robotics, and wearables. Perhaps the biggest leap forward was made in the realm of virtual care, especially in nursing.
Back in August, HealthLeaders spoke with nurse leaders who are turning to virtual nursing to address staffing and wellbeing, and to learn how they will adapt and advance to this new technology.
The future is now
The use of telemedicine following the COVID-19 pandemic kick started the virtual nursing movement. And while some systems are just getting started, many have been utilizing virtual nursing for years and continue to expand.
In fact, according to Steve Klahn, system clinical director for virtual medicine at Houston Methodist, virtual nursing roles are about to expand exponentially. Klahn predicted that within the next five to 10 years, 60% to 70% of nursing positions across the industry will become virtual or have a virtual component.
"I'd say well over half," Klahn said, "just with [the] massive growth and expansion over the last two years."
Klahn explained that this is largely due to the response to virtual nursing programs.
"This is going to stick with us for a while," Klahn said, "understandably so, because there's such positive response to programs that are engaging a virtual component or fully virtual."
Dr. Shakira Henderson, dean and chief administrative officer and associate vice president for nursing education, practice, and research at the University of Florida College of Nursing, and the system CNE of UF Health, said this strategy will transform the landscape of nursing by enhancing care and improving efficiency.
"One of the facts that struck me was that we are going to produce now the first generation of nurses who could potentially never touch a patient," Henderson said.
Get ready for the new care model
Leaders must keep in mind that with every new wave of technology, there will be an adjustment period as the technology is integrated with workflows. That won’t be any different with virtual nursing.
Klahn said the standard care model for nursing will be highly comprehensive, due to the integration of virtual nursing. It will include both task-driven support from remote nurses and a new way of collecting biometric data.
Nurses will soon be able to monitor a wide variety of healthcare data including blood pressure, heart rate, and respiratory rates through remote patient monitoring, according to Klahn. The collected data can be automated and synthesized through a software system and delivered to the experienced clinical personnel that are remotely supporting bedside teams.
This new model also enables non-traditional nursing ratios in the form of paired nursing teams, where the bedside nurse can take on more patients while moving a portion of their workload to the virtual nurse.
"Now you can actually have one or two nurses supporting a much larger group of patient populations," Klahn said, "and truly load balancing and taking those calls as they come in and reducing the wait times for that process."
The stopgap budget bill gave key telehealth and Hospital at Home waivers a three-month reprieve. Supporters now have to convince a fractured Congress and new Administration that these waivers are crucial enough to be made permanent.
Telehealth and digital health policy will remain a hot topic in early 2025. But will three months be enough time to convince a fractious Congress and new Administration of the benefits of permanent coverage?
Telehealth advocates and supporters of the Hospital at Home strategy are celebrating what amounts to a moral victory in the last-minute passage of a stopgap budget bill. The 100-page bill—which originally clocked in at 1,500 pages before it was pared down to make the grade—includes extensions of key telehealth waivers and a continuance for the Centers for Medicare & Medicaid Services (CMS) Acute Hospital Care at Home (AHCAH) program.
But those waivers only extend another 90 days—barely enough time to schedule an in-person doctor’s visit--and several other digital health and telehealth provisions were cut.
Supporters are now continuing their full-court press on Congress to make those provisions permanent, something they’ve been working on for several years. They’re hoping the letters to lawmakers signed by hundreds of healthcare organizations and support of dozens (if not hundreds) of House and Senate members will sway Congress.
“We will immediately begin working to ensure Congress makes Medicare telehealth flexibilities and the Acute Hospital Care at Home Program permanent—or secures a much longer extension than 90 days,” Kyle Zebley, senior vice president of public policy for the American Telemedicine Association and executive director of ATA Action, the group’s lobbying arm, said in a press release. “Simultaneously, we will advocate vigorously to reinstate the vital provisions that were left out of this package.”
On one hand, supporters are encouraged by the fact that the telehealth and ACHAH waivers made the cut for the three-month extension—meaning Congress thinks they have enough value to continue. On the other hand, those waivers have been extended before, and the incoming Trump Administration has signaled its interest in cutting costs and reducing administrative clutter. The challenge will be on supporters to push the value in making these waivers permanent.
The final bill includes a 90-day extension (instead of two years, as was in the original bill) on several telehealth flexibilities enacted by CMS during the COVID crisis to expand coverage of and access to telehealth. They include:
Waiving geographic restrictions on telehealth coverage and use;
Expanding the list of providers able to bill Medicare for telehealth services;
Allowing audio-only telehealth services;
Easing originating site restrictions on telehealth so that the patient can receive treatment at home;
Waiving the in-person requirement for telemental health treatment;
Enabling telehealth service for hospice care; and
Enabling Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to use telehealth.
In addition, the bill extends the CMS waiver for its AHCAH program for three months, instead of five years, enabling the more than 350 health systems following the CMS model to receive Medicare reimbursement.
Among the telehealth provisions that were cut out of the final package:
First dollar coverage of High Deductible Health Plans (HDHPs) and Health Savings Accounts (HSAs);
Support for virtual care providers in the Medicare Diabetes Prevention Program;
Improved coverage for digital health in home-based cardiology and pulmonary rehab programs; and
The SPEAK Act (HR 6033), which paves the way for accessible telehealth services.
CMS has already said it won’t extend the waivers any more (though the agency did include some telehealth, remote patient monitoring and digital therapeutic improvements in its 2025 Physician Fee Schedule). So it's up to Congress to decide if there's enough value in the waivers to make them permanent.
