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Chief Nurses Bring Overarching Perspective to a Hospital's Senior Leadership Table

Analysis  |  By Carol Davis  
   March 28, 2022

Trinity Health's top nurse makes it her mission to prepare the health system's chief nurses to be strategic partners within their own hospital's leadership team.

A hospital or health system's chief nursing officer (CNO) is unparalleled in the direct link to patient care, so it is "a miss" if the organization doesn't welcome that lineal perspective to the senior leadership table, says nurse executive Gay Landstrom, PhD, RN, NEA-BC, FACHE.

Landstrom, senior vice president and CNO of Trinity Health, has a seat at the table and helps prepare the health system's CNOs to be strategic partners within their own hospital's leadership team.

Through mentoring, development, and leadership programs, Trinity CNOs gain the skills necessary to plan organizational strategy and make high-level decisions.

HealthLeaders spoke with Landstrom about her work with CNOs to prepare them to be part of their organization’s leadership team.

This transcript has been lightly edited for length and clarity.

HealthLeaders: How far along, right now, are nurse executives in getting seating at a hospital or health system's leadership table?

Gay Landstrom: I've been in a CNO role since 1994 and a system chief nurse since 2009, and over that time, there has been a steady evolution of organizations recognizing that the chief nursing officer is not just the person who's running a big part of an organization, hospital or otherwise. CNOs are responsible for a lot of the operations—usually the biggest chunk of the people who work in an organization. Because they have such direct access to the biggest chunk of the workforce, and it's their workforce that is directly caring for the customer—the patient—they have a direct view of the service, or care, that's being provided every day.

They're also creative. They see what doesn't work well. Many CNOs are innovative in their view as to how we could do this better and better meet patient care needs or improve quality or improve safety. So, it's a miss if you don't have the chief nursing officer at that senior leadership table where strategy is discussed and decisions are made.

That said, not all organizations are there, but there's been a steady evolution. From a system standpoint, even a dozen years ago, there weren't a lot of people who had experience doing what I do as a system CNO and now there really are. We probably tripled or quadrupled the number of system chief nursing officers, and in the system, chief nursing officers very typically are sitting at the executive strategy tables.

HL: How prepared are most CNOs to be strategic partners within their hospital's leadership team?

Landstrom: We've probably talked about it for at least a couple of decades, that historically, did we take a great clinician and make them a nurse manager? Absolutely. But we've recognized that we've got to start developing those people and, if possible, develop them before they take that kind of responsibility.

That development is a constant process. One of the things that we work on developing is their ability to be strategic. Within my organization, Trinity Health, we have a strategic leadership program, and we get new CNOs right into it to make sure that they have a good dose of not only thinking strategically and understanding the theoretical underpinnings of strategy, but that they get to collaborate with multidisciplinary teams.

One of the important skills you have to have as a CNO is not just knowing nursing; you have to be able to work with and translate to lots of other disciplines, where they have a financial, strategic, or marketing background. You have to be able to translate and tell stories and convey what it is that you know, in ways that can be understood. Not everybody has that innate ability, so we work on developing that.

The other thing is education for nursing leaders has evolved. I have for a number of years advised if someone wants to become a CNO they have to look at getting started with their doctoral education because that helps augment that that ability to think in different ways and think strategically and creatively.

HL: You've touched on this briefly, but let's talk a bit more about what CNOs uniquely bring to the leadership team.

Landstrom: I often will find myself on a leadership team with the most realistic and current knowledge of what our colleagues, employees, and clinicians might be struggling with day to day [and] what their work is, what their challenges are, and what barriers might stand in their way, as well as what the issues might be with pipelines for developing our workforce in coming years.

And while other people might have pieces of information—like the human resource officer might be aware of the numbers and where we hire people from—I'm the one that's thinking about the pipeline and the relationships with schools and making sure that we will have an adequate flow for coming years.

For the workforce, I will often need to be the one that really can tell the story of what's happening at the bedside—why patients might be frustrated or what new barriers are being encountered by our employees as they're caring for patients. So very often, I might be the only one carrying that kind of perspective of the primary product that we deliver as a health system.

There usually is a physician at the table, and they understand the medical side of things and one aspect of patients, but it's my employees who are with them 24 hours a day, and it usually is nurses with whom patients will be most honest and forthright about their concerns, their worries, their frustrations, and so forth.

So that is often what I have to bring into that discussion. As we're considering our challenges and what decision options we might have, I have to be sure I represent all those pieces, so we take them all into account as we make decisions.

HL: What are some of the tools necessary, then, for the next generation of nurse leaders to be strong organizational leaders?

Landstrom: I'll preface this by saying I have some pretty strong opinions about this and not all my colleagues necessarily think this way. CNOs have to have strong relationship skills. They have to learn how to lead in an environment where they're empowering clinicians and not making the rules and telling people what they need to do. They must engage people in governing their own practice and improving that practice and help people participate in better understanding the system and helping make decisions to make it better. That's just an essential skill.

And here's the part that people don't always think about. The health systems that we have today increasingly are not hospital systems. There are some that are purely acute care, but with more systems, you have acute care hospitals, post-acute services, long-term care, and PACE [All-Inclusive Care for the Elderly] programs. You've got a lot of different healthcare and distinct parts of the continuum.

Many CNOs grow up in acute care; it's where the largest numbers of RNs practice still, but CNOs of the future need to learn more than acute care. They need to gain experience in other parts of the continuum and have an appreciation of what is different and how all the pieces fit together because frankly, our patients flow through that whole continuum. And if all you understand is one part of it, then I don't think you can do justice to the role.

One of the things I'm developing right now is a fellowship that gives an aspiring leader the ability to have some time with different parts of the continuum and give them that appreciation of how all these pieces fit together so that they have the perspective they need to be a strong CNO.

“Historically, did we take a great clinician and make them a nurse manager? Absolutely. But we've recognized that we've got to start developing ... them before they take that kind of responsibility.”

Carol Davis is the Nursing Editor at HealthLeaders, an HCPro brand.


In the past decade, the number of chief nurses sitting at executive strategy tables has tripled or quadrupled.

A CNO must work with and translate to other disciplines with other backgrounds, such as financial, strategic, or marketing.

CNOs of the future must gain experience in multiple parts of the healthcare continuum to understand how it all fits together.

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