Date of Graduation
Doctor of Nursing Practice (DNP)
School of Nursing and Health Professions
Executive Leader DNP
Dr. KT Waxman
Dr. Sara Horton-Deutsch
Problem. In a 21-hospital region of a 39-hospital integrated health system, CNE turnover peaked at 63% (12 CNEs) in 2015. Interviews were conducted in 2019 with 12 CNEs across the region to understand potential issues related to CNE job satisfaction. Responses revealed concerns regarding empowerment, alignment, work-life balance, information transparency/sharing, and recognition. While identifying a solution to address CNE concerns, the organization experienced successive crisis events during a 12-month period that included a record-setting wildfire, multiple labor union strikes, and a novel pandemic. The regional leadership team (RLT) required new approaches to facilitate effective communication during a crisis between the regional office and local hospital CNEs.
Context. As far back as 1988, an ongoing chief nurse executive (CNE) role crisis is identifiable in the literature. The crisis is attributable, at least in part, due to an environment that lacks focus on the importance of cultivating a positive and sustainable work environment for the nurse leader in practice. Although the nurse executive plays a central role in the hospital and nursing organization's culture, there is almost no literature that explores engagement at the nurse executive level in single or multiple hospital systems. Since the Affordable Care Act's implementation, health system mergers increase the frequency at which hospitals work together under a regional or system office; mergers often create multi-executive teams led by a regional or system CNE.
Interventions. For the literature review and DNP project, the PICOT question is in CNEs (P) does a communication strategy (I) compared to no strategy (C) impact work engagement (O) in 8 months (T)? Although there are no direct instances in the literature that examine measuring and improving CNE engagement, there are ample examples of similar activities in frontline nurse leader populations, including nurse managers and nurse directors. Relevant to the CNE population, work engagement complements examining existing literature on CNE turnover, role stress, and burnout. The first aspect of the intervention was introducing weekly work engagement measurement using a commercial product called OfficeVibe®; the product measures engagement every week, sending a simple 5-question survey. The second facet of the intervention was to design and implement a technology-driven communication strategy that cultivates community at work, provided rewards and recognition, aligns values, and strengthens culture within and across the local CNEs and the RLT group.
Measures. Outcome analysis focused on OfficeVibe® engagement scores pre- and post-intervention. Process measures of the communication strategy were: (a) number of virtual huddles; (b) number of daily consolidated reports distributed; (c) number of weekly huddle messages distributed. The balancing measure was CNE turnover.
Results. The decrease in annual CNE turnover of 2 CNEs was statistically significant t(8) = 22.91, p < .001. Overall work engagement score decreased from 7.6 in December 2019 to 6.1 in August 2020 and was statistically significant t(62) = 16.95, p < .001. Eight out of 10 sub-domains of the engagement score experienced a statistically significant decrease: recognition (-2.5), alignment (-2.2), personal growth (-1.9), satisfaction (-1.4), and relationship with manager (-1.4) sub-domains, while smaller decreases occurred in the feedback (-1.3), and relationship with peers (-0.2). Ambassadorship decreased (-1.1), and happiness reflected no change from baseline, and both were not statistically significant. NetPromoter Score decreased from 50 to -5 (-55) points which was statistically significant t(62) = 9.45, p < .001. Participation starting value was 100% in December 2019 and ended at 44% in August 2020. Decrease in participation (56%) over the course of the intervention was statistically significant t(62) = 19.08, p < .001. Throughout the intervention's 8-months, the virtual communication strategy's implementation resulted in 96 virtual huddles, 87 daily consolidated reports, and 16 weekly huddle messages.
Discussion. Although CNE turnover was lower than average during the eight months of the project, many factors likely contributed to the decrease. OfficeVibe® was a significant and low-cost commercial product to measure work engagement. The project's original intention was to design and implement a comprehensive CNE work engagement strategy, yet the successive crisis events, including the COVID-19 pandemic, required the project to focus more specifically on communication and information sharing. The overall decrease in work engagement scores was disappointing, but it reinforces the paradigm that CNE work engagement is essential to measure on an ongoing basis at the micro-, meso-, and macrosystem level. The results reflect issues that need to be addressed within the organization and more broadly within our profession. These issues, such as unsatisfactory work-life balance, high levels of stress, and the development of an "us vs. them" mentality within large systems, otherwise may go unacknowledged and unaddressed.
Conclusion. This DNP project merely broaches the topic of CNE work engagement, and further research in this area is needed. The lack of published literature on the topic is concerning, and attitudes towards work engagement at the executive level must be considered. Communication tactics introduced in this project proved helpful during the crisis events, but a more robust work engagement strategy was needed. Complex workforces evolve from system mergers that do not reflect the past's health system, yet instead that of the future. Appreciating the “systemness” that evolves from complexity thinking requires organizations to begin acting more deliberately in support of their human capital – this is especially true at the executive level. Much like frontline nurses and nurse leaders, executives require purposeful support, growth, and development to be successful. Expectations of CNEs in practice must shift towards more reasonable and healthy working conditions that foster their ability to thrive. Nurse executive leadership is already in short supply, and a lack of attention to the quality of their work environment is a recipe for exacerbating future workforce shortages. Leveraging lessons learned from existing nurse manager and frontline work engagement studies, the CNE population is sure to benefit from an increased focus on work engagement in the high-stress, high-stakes role they occupy.
Fuller, Ryan, "Chief Nurse Executive Work Engagement: System Leadership Through a Natural Disaster, Strike, and Pandemic" (2020). Doctor of Nursing Practice (DNP) Projects. 232.
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