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Nurses Rise to New Levels in the C-Suite

Analysis  |  By Jennifer Thew RN  
   April 13, 2020

No longer are nurses limited in the senior leadership positions to which they can aspire. Nurses have the skills and knowledge for success in a variety of C-suite roles to make healthcare better.

This article appears in the March/April 2020 edition of HealthLeaders magazine.

The annual rate of CEO turnover is significant. According to a report by the American College of Healthcare Executives, it has hovered around 18% for the past five years. And considering the reality of retirements, new professional opportunities, and mergers and acquisitions, turnover in the C-suite is not going away anytime soon.

Thus, it might be wise to reflect upon your organization's succession plan. Does it have one?

The odds are about even that your answer could go either way. In fact, almost half of the respondents to the American Hospital Association's 2019 National Health Care Governance Survey Report said their organization did not have a formal CEO succession plan. Knowing that leadership transitions are bound to occur, it makes sense to actively identify individuals who show strong leadership potential and to nurture and develop their skills, so they are ready when those transitions take place.

With healthcare being such a complex industry, it may seem daunting to find leaders who can run a successful business and make decisions that contribute to the health and well-being of individuals and communities. Healthcare literally has lives on the line. Yet, there is a group of professionals whose members are ready to rise to the challenge of steering the ship toward new horizons—nurses. 

If you are now thinking about all the excellent chief nursing officers you know (and there are many), that's a step in the right direction. But don't stop there. Don't pigeonhole nurses into one executive track. Their leadership skills, industry know-how, and dedication to patients transcend professional silos. In other words, nurses can do any job the C-suite has to offer.

In fact, nurses have broken through healthcare's glass ceiling and have come out on the other side as CEOs, CFOs, and chief business development officers. They've grown organizations, managed large portfolios, and fixed flawed systems that were preventing patients from getting optimal care. Not only do they know what it takes to get the job done—because they've been at the bedside—they also know how to make it better.

"I think you're absolutely seeing that more nurses are moving into what I would refer to as nontraditional roles," says Joyce Markiewicz, RN, BSN, MBA, CHCE, executive vice president and chief business development officer at Catholic Health in Buffalo, New York. "[In healthcare], we're asking people to look at new and innovative ways of providing care, and I think many of those answers come from people who have worked at the bedside. They know what can work and what can't work. It's giving nurses an opportunity to say, 'I can get a degree in business … or I can make a bigger difference if I can be the one at the top of the organization that's actually driving care.' "

Three healthcare executives, including Markiewicz, who have advanced from the bedside to the C-suite share how their backgrounds as nurses have helped them find success leading organizations—other than in CNO roles—and bring viable solutions to their organizations.

The Chief Business Development Officer: Growing Business Opportunities for Hospitals and Health Systems

Before giving a recent commencement speech at her nursing school alma mater, Markiewicz says she was asked about the biggest surprise in her career.

"I never thought that when I graduated from nursing school that the sky would be the limit," she says, recalling her answer. "Having that degree has opened up so many doors that I never even imagined could be opened."

After graduating, Markiewicz began working as a nurse in an inner-city hospital down the street from the school she had attended.

"I enjoyed my time working at the inner-city hospital. I learned a lot of life lessons. I was very young and a suburban girl and I learned how other people lived. It was very eye-opening for me and a wonderful experience. It also afforded me the opportunity to do things that I wouldn't do in a bigger hospital," she recalls.

That desire to help the underserved is what eventually launched Markiewicz's healthcare business development career, she says. After volunteering for Meals on Wheels, she says she decided to work in the home healthcare environment. Then, after applying to a few homecare agencies, she was offered a position as director of nursing.

"They said, 'We realize you don't have the experience, but you've done Meals on Wheels. You know what it's like for patients in their homes, and we really think that you could do a good job leading our nursing staff.' So, I said, 'What the heck? I'll give it a try,' " she says.

As the director of nursing, Markiewicz says she realized she had a knack for business development.

"I discovered that I enjoyed growing the business using my clinical hat. We did a lot of pediatric care. I would go to the local children's hospital and talk to families about the care their child needed and how we would set up that care. Then the families would choose our agency," she says.

She eventually became a branch manager for the home healthcare agency. Additionally, she worked for a few other homecare organizations.

"Each organization offered me something that afforded me greater responsibility and greater opportunity to learn more about the industry," Markiewicz says.

However, she says she realized that to continue to grow in the field, she needed to return to school. She earned her MBA while working at a company that supplied respiratory, pharmacy, and durable medical equipment services.

Markiewicz was eventually recruited by Catholic Health as vice president of operations for McAuley-Seton Home Care. At the time, the home healthcare agency was struggling.

"It needed a turnaround. It was interesting for me because this was my first stint in a not-for-profit. I took a lot of for-profit principles and applied them to the expectations for McAuley-Seton," she says. "A lot of it was around productivity and managing the day-to-day operational components, and then growing the business."

She says some of those growth opportunities included purchasing the pharmacy component from her previous employer and getting a liaison to connect with a large cancer institute to help generate outside business and grow the home healthcare division.

Grow your way to success

"I don't believe you cut your way to success. I believe you have to grow," Markiewicz says.

Having a nursing background has helped her understand what makes or breaks a good business development opportunity, she says.

"Because I've been at the bedside, I look at things through a different lens. When I'm looking at a potential business opportunity, I don't always just look at what does it do to the bottom line," she says. "Of course, that's an important component of it, but I also try to look at how it aligns with the mission of Catholic Health and what it's going to do for the patient. Does it improve access to care? Is it going to provide a better service? Is it something that people need? Is it what they want?"

Markiewicz says she also looks at how business decisions impact staff members.

"[Often decision-makers will say] the nurses can do this or add that to their day-to-day routine. I try to take a look at [decisions] and ask, 'Are we asking people to just keep doing more and more? Is it really going to bring value?' " she says.

Her clinical knowledge also enables her to connect with a broad group of stakeholders when making business decisions.

"Having that clinical knowledge [allows me] to be able to sit with a variety of different people, whether it's nurses, business people, or a group of doctors. I certainly understand the language that they speak. I think being a nurse lends itself to a credibility when I talk about something that is clinical in nature. I do think that I'm respected more for that clinical knowledge," she says.

Hiring leaders with this pairing of clinical knowledge and business sense can benefit organizations.

"When … you bring those two things together, it really can create some magic," she says.

The CEO: Strong Leaders Build Strong Teams That Get Results

When Flo Spyrow, RN, MSN, MPA, MHA, JD, FACHE, began her career in healthcare, she says she had no plans to go into leadership. Today, as president and CEO at Northern Arizona Healthcare (NAH) in Flagstaff, Arizona, she leads an entire health system.

Spyrow began her career as a nurse in a neonatal ICU in Portland, Oregon, which she affectionately refers to as a "MASH unit" because of the intensity of the experience.

"We transferred babies from all over Oregon and Southern Washington. It was all hands on deck every single night," she says of her time there. "But I loved the opportunity to care for patients and to make a difference. I had no intention of going into leadership."

But a relocation to California's Central Valley and a strong opinion about a dress code changed all that.

"We moved to a small town and there were two hospitals. I interviewed at the private, Catholic hospital and the nun said, 'We'd love to have you, but you have to wear a nurse's hat, a skirt down below your knees, and white stockings,' " Spyrow recounts. "Then I went to the community hospital and the only position they had open was a management position. I always laugh that I went into leadership not because I had a passion about leading, but because I didn't want to wear a nurse's hat, skirt down below my knees, and white stockings."

However, once she took that first nurse manager position, Spyrow says she became hooked on leadership.

"I loved leadership because it was an opportunity to make a difference for physicians and staff and impact more patients than just one very ill neonate," she says.

Spyrow's career eventually pointed to her becoming a CNO. However, she says, the CNO role didn't fit her ambitions.

"The CNO was a very traditional role and, at that point in time, nurses were being kind of pigeonholed into 'this is your role.' I wanted to do and experience other things and learn more about healthcare and the delivery of healthcare," she says.

So instead, Spyrow went to law school with the intention of doing defense work, working with providers on how to safely care for patients, and avoiding lawsuits. She worked as in-house counsel at Trinity Regional Health System, part of what is now UnityPoint Health, for about eight years. While there, her career path took another turn, and she was asked to fill a few administration positions, including VP of operations and even interim CMO.

"As in-house counsel, I had the opportunity to build relationships with the board of directors, physicians, multiple levels of leadership, and staff. I also had the opportunity to work on several significant projects, such as purchasing a hospital in an adjoining community in another state," she says.

"This purchase allowed us to become a bistate health system, providing integrated care for people who lived in one state but worked in another and improving access to healthcare in that community. We also affiliated with what is now UnityPoint Health, providing expertise across the continuum of care and more effective contracting strength. In that work, I built trust and respect throughout the organization," says Spyrow.

She continues, "The CEO that I worked for at the time taught me that leadership was about building strong relationships and then leveraging those relationships to get things done—who else would choose an attorney to be the interim CMO? He chose me for these roles … because of my success in leading the organization through several major initiatives and because of the strong relationships I had built throughout the organization. 

"I loved administration and working with clinicians, physicians, and the people who were taking care of patients. So, when I had an opportunity to stay in administration, I gave up my law career," she says. 

Spyrow eventually came to NAH as the chief administrator officer of Flagstaff Medical Center, and when the CEO there left, she stepped in as interim CEO. In October 2018, she became president and CEO of NAH.

Varied experiences matter

It's fair to say that Spyrow's career has been all over the map, but having a variety of career experiences is beneficial for nurses, she says.

"The career path for a nurse leader has traditionally led up to the CNO. Nurses can add value in many different roles in healthcare because they bring a passion for our patients. Providing experiences for them in ambulatory care, service line leadership, or physician practice management will broaden their understanding of the complexities of healthcare, enabling them to gain a broader perspective and be better leaders," Spyrow says.

That's why she encourages nurses to be open to new opportunities.  

"[The advice I would give] to nurses is, don't have a defined career path. Take advantage of opportunities that open up for you and have the courage to try them if you think it is work that you could contribute to and that you would be passionate about," she says.

Spyrow says that nurses can use their passion for patient care to inform their work in leadership roles. Because they have served at the bedside, nurses understand both the needs of the patient and the complexities of delivering care. 

"At the heart of all we do, we are entrusted by the communities that we serve to deliver high-quality, safe care to every patient, at every location, with every encounter. That is now my passion as a leader, and that passion came from my experiences as a nurse," Spyrow says. 

"Nurses have a broader view of the patient," she notes. "They intuitively understand systems based on their skill sets and their training." Plus, nurses often have a strong desire to fix flawed systems that interfere with patient care, she says.

"[As a nurse], I left work being really frustrated because lots of stuff got in the way of taking great care of patients. Now, I have the passion for patient care and for creating great work environments so our staff can learn to love their jobs again," Spyrow says.

For example, at NAH they have implanted technology such as Smart Rooms, to more effectively engage patients and worked to decrease documentation in the EHR so nurses can spend more time at the bedside. Smart Rooms bring information on a patient's health condition directly to their room and better prepare them for adherence to care plans after discharge. In this way, says Spyrow, NAH is transforming patients' experience and expectations.  

"In our journey to high reliability, we have implemented many standardized practices to make it easy to 'do the right thing.' And we insist on 'consistent and effective leadership in every nook and cranny' of NAH, as individual leaders significantly impact each department's work environment," she says.

In addition to annual nursing and employee engagement surveys, the organization also sets measures for individual initiatives, such as nursing admission documentation time.  

Teamwork leads to success

Additionally, nurses bring a sense of collaboration that's needed among healthcare leaders.

"Nurses are trained to be team players. I think that is what healthcare needs now—strong teams and people who are willing to reach across the aisle and work together and with multiple stakeholders in order to transform the way we deliver care," Spyrow says.

These are qualities she says she looks for when hiring for her leadership teams.

"I look for people who can build relationships, work well with multiple different people, who will care deeply about the people who work for them, and who will be great team players. In healthcare organizations today, strong teams get strong results and determine whether an organization is successful," she says.

Spyrow has advice for nurses who wish to take on leadership roles.

"[Those nurses should b]roaden their skill set throughout the organization and get into a nontraditional nursing role, whether that be strategy, business analyst, etc.," she says. "Leadership is about building relationships and then being able to leverage those relationships to do the hard work."

The CFO: Bridging the Financial and Clinical Realms

Karen Testman, RN, CFO at MemorialCare in Fountain Valley, California—a Southern California health system­—grew up in a family of healthcare providers. She says when she announced her intention to follow that tradition and become a nurse, her father suggested she pursue a career in business.

"Sometimes your parents know you better than you know yourself," she says. "While I [thought it] was interesting to hear his perspective, I was still going to pursue nursing as my career." 

However, she says her father's inkling that she would do well in business proved correct. During nursing school, Testman says she became interested in learning more about how hospitals operate.

"It started piquing my interest about the business side of healthcare," she says. "While I was working as a nurse, I worked in a medical-surgical unit. I enjoyed it but felt like I wanted to utilize my experience and passion for the nursing profession in a role that could combine nursing with the operations side of healthcare; therefore, bringing experiences and sensitivities of the nursing profession into the business side of healthcare."

She says she went back to school to pursue a business degree, and from there it was love at first spreadsheet.

"I took my first accounting class and loved it, and decided I wanted to focus on accounting," she recalls.

After finishing college, Testman worked for a public accounting firm as an auditor in Arthur Andersen's healthcare practice. She then took those skills to Catholic Healthcare West (now CommonSpirit Health) where she worked as the controller at St. Bernadine Medical Center. From there, she became the regional director of finance for the Southern California region.

She joined MemorialCare in 1998 as CFO at Orange Coast Medical Center, and then spent time as CFO for both the Orange Coast facility and the organization's Saddleback Medical Center.

After five years in those positions, she took on the systemwide role of senior vice president of financial operations. Then in 2013, she took on the role of MemorialCare's system CFO where she is responsible for overseeing the $2.5 billion organization's financial operations.

"It's a big job, but it's a great job," she says. "I've also been pretty involved over the past five to six years in our ambulatory strategy. We have four major hospitals and more than 200 ambulatory care locations. I assist with strategic initiatives and acquisition and facility transactions. Most recently, I'm heavily involved in the development of our joint venture strategy."

Problem solving is common ground

Testman says her nursing background has greatly informed her finance career.

"I have a real understanding of hospital [operations] and, to some extent, medical office operations. I have an appreciation and understanding for what the frontline caregivers are facing and what their challenges are. I believe it helps me relate better, and I'm genuinely curious and interested in what they have to say about both the challenges and opportunities they experience," she says.

She also says her experience as a nurse helps her to connect with clinical leadership and staff.

Testman says that one example of working with clinicians includes the organization's "strong and close collaboration on information technology to make it easier for nurse leaders and bedside nurses to simplify some of their administrative tasks and improve processes so they can maximize their time with patients." These include areas such as how nurses address supply chain activities, patient education, and managing and simplifying shifts worked and payroll processes.

These activities help to "improve productivity and workflow and identify and initiate cost savings. While this work may be perceived as time-consuming, it generally results in initiatives that are time saving. As nurses, we have a shared understanding of what it takes to deliver care to patients," she says. "Having similar backgrounds adds credibility to my role. They know I have an appreciation of what it's like to care for patients at the bedside."

One example is a recently approved project to replace the supply cabinets on the patient care units that contain various patient supplies needed by the clinical care team with an easier-to-access storage unit. "This new unit allows us to continually monitor electronically the volume and level of supplies to ensure that supplies are quickly and easily replenished when needed," says Testman.

Another example is the revamping of MemorialCare's case management and utilization review functions to improve patient flow through standardized processes across the healthcare enterprise and move utilization management to the revenue cycle function to help further address the denial challenges. 

And though their education is different—accounting courses versus science courses—Testman says nurses and finance professionals share quite a few positive qualities.

"From my perspective, what's similar about nursing and finance is that analytical skills are fundamental to both professions. Nurses are analyzing constantly, and they're trained to continually assess the patient. Assessment and analysis are also a key component of what CFOs do every day. Both [groups] look at data and information, talk with people, and assess situations, continually looking for opportunities to improve. I believe there are many similarities in how a CFO thinks and how a nurse thinks, and in both cases, you tend to find people that want to solve problems and make healthcare better for our patients." 

She notes that the educational path to financial leadership isn't necessarily set in stone, either.

"There isn't one way to gain the skills and background to be a finance leader. I think there are many paths to that. I would tell a nurse that it is important to have a core basic understanding of accounting and finance, and there is more than one way to achieve that," Testman says.

Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.

Photo credit: Flo Spyrow, RN, MSN, MPA, MHA, JD, FACHE, is president and CEO of Northern Arizona Healthcare in Flagstaff, Arizona (Mark Peterman/Getty Images).


Nurses possess the skills to be leaders other than CNOs in an organization's C-suite.

Because of their frontline patient care experience, nurses can connect with clinicians to move an organization toward its goals.

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