Enhancing Competency and Performance: An Evidence-Based Leadership Initiative for Novice Chief Nursing Officers in a Local Health System

The chief nursing officer (CNO) plays a well-documented role in fostering a thriving culture for both nurses and patients. Inadequate orientation of new hospital CNOs can result in unstable clinical care environments, escalate nurse turnover, incur significant financial and operational costs, and degrade quality outcomes. Research supports dedicated leadership orientation programs. A local Mountain West health system provided minimal formal training of eleven new CNOs, potentially precipitating underperformance in their responsibilities relative to receiving an optimal onboarding process. The purpose of this Doctor of Nursing (DNP) initiative was to enhance the knowledge and competency of new chief nursing officers within the health system through the development and implementation of an evidence-based leadership program, including training, a toolkit, and customized resources. This initiative adhered to the Johns Hopkins Evidence-Based practice model to develop orientation materials that enhance the knowledge and competence of new chief nursing officers. These materials covered content from the AONL Nurse Executive Competencies and included a resource toolkit and assignments to create relevant documents for hospital and nursing operations. The content was organized into seven training sessions. This eight-week initiative took place in eleven hospitals in the Mountain West, including academic, trauma, community and critical access facilities. Each facility designated one novice CNO to engage in the orientation program, culminating in a total of eleven leaders. In addition to weekly group training, each participant received a one-on-one session, allowing for Plan Do Study Act (PDSA) cycles to enhance their learning. Pre- and post-intervention surveys and a competency assessment were administered to determine efficacy of the intervention, using descriptive and inferential statistics to analyze the findings, including the Wilcoxon Signed-Rank (alpha=.05). The pre- and post- intervention survey analysis suggested statistically significant increases with medium to high effect sizes in four areas: post-intervention perceptions in confidence and knowledge of the hospital CNO role (p=.020, r=.703), barriers limit me to excel in my role as a CNO (p=.023, r=.685), resources needed to fully succeed as a CNO (p=.034, r=.640), and awareness of resources available that can help manage job stress (p=.046, r=.603). Participants liked the broad overview of a spectrum of topics, peer CNO support during the sessions, and the resources provided. Participant suggestions for improving the training included more focused time on financial concepts, providing sessions in-person for more interaction with peers, and a longer orientation program. The program was deemed successful and will be adopted for continued use in the health system to train new CNOs. Future cohorts would benefit from extending time for a longer orientation period, in-person discussions, and individual assessments of the leader in areas of emotional intelligence, personality, and behaviors to create a personalized development plan.

1 Enhancing Competency and Performance: An Evidence-Based Leadership Initiative for Novice Chief Nursing Officers in a Local Health System Amy B. Christensen, Scott Christensen College of Nursing: The University of Utah DNP Scholarly Project March 30, 2025 2 Enhancing Competency and Performance: An Evidence-Based Leadership Initiative for Novice Chief Nursing Officers in a Local Health System Abstract Background: The chief nursing officer (CNO) plays a well-documented role in fostering a thriving culture for both nurses and patients. Inadequate orientation of new hospital CNOs can result in unstable clinical care environments, escalate nurse turnover, incur significant financial and operational costs, and degrade quality outcomes. Research supports dedicated leadership orientation programs. Local Problem: A local Mountain West health system provided minimal formal training of eleven new CNOs, potentially precipitating underperformance in their responsibilities relative to receiving an optimal onboarding process. The purpose of this Doctor of Nursing (DNP) initiative was to enhance the knowledge and competency of new chief nursing officers within the health system through the development and implementation of an evidence-based leadership program, including training, a toolkit, and customized resources. Methods: This initiative adhered to the Johns Hopkins Evidence-Based practice model to develop orientation materials that enhance the knowledge and competence of new chief nursing officers. These materials covered content from the AONL Nurse Executive Competencies and included a resource toolkit and assignments to create relevant documents for hospital and nursing operations. The content was organized into seven training sessions. Interventions: This eight-week initiative took place in eleven hospitals in the Mountain West, including academic, trauma, community and critical access facilities. Each facility designated one novice CNO to engage in the orientation program, culminating in a total of eleven leaders. In addition to weekly group training, each participant received a one-on-one session, allowing for Plan Do Study Act (PDSA) cycles to enhance their learning. Pre- and post-intervention surveys 3 and a competency assessment were administered to determine efficacy of the intervention, using descriptive and inferential statistics to analyze the findings, including the Wilcoxon Signed-Rank (alpha=.05). Results: The pre- and post- intervention survey analysis suggested statistically significant increases with medium to high effect sizes in four areas: post-intervention perceptions in confidence and knowledge of the hospital CNO role (p=.020, r=.703), barriers limit me to excel in my role as a CNO (p=.023, r=.685), resources needed to fully succeed as a CNO (p=.034, r=.640), and awareness of resources available that can help manage job stress (p=.046, r=.603). Participants liked the broad overview of a spectrum of topics, peer CNO support during the sessions, and the resources provided. Participant suggestions for improving the training included more focused time on financial concepts, providing sessions in-person for more interaction with peers, and a longer orientation program. Conclusion: The program was deemed successful and will be adopted for continued use in the health system to train new CNOs. Future cohorts would benefit from extending time for a longer orientation period, in-person discussions, and individual assessments of the leader in areas of emotional intelligence, personality, and behaviors to create a personalized development plan. Key words: CNO, chief nursing officer, nurse leader, nurse executive, orientation, onboarding, training, hospital, competency, knowledge, program, performance, confidence. Problem Description Nurse leadership roles are inherently challenging and experience frequent turnover, compounded by those retiring from nursing at the culmination of their careers (Ramseur et al., 2018). Such transitions can be complex, resulting in nurse leaders feeling anxiety and discomfort as old roles are left behind and new roles are not yet developed (Kauffman & Aucoin, 2023). 4 This instability from novice leadership is even seen among chief nursing officers (CNOs), who perform a vital role within healthcare facilities driving nursing professional practice, balancing system and site priorities, developing the nurse workforce, and leading their organization in times of changing healthcare reimbursement (Batcheller et al., 2019). Failure to succeed in these responsibilities can result in unstable clinical care environments, increased nurse turnover, significant financial and operational costs, and altered expectations (Bernard, 2021). Nurse leaders must have the necessary preparation and orientation to succeed in their roles (Ramseur et al., 2018). Researchers and healthcare organizations, including the American Organization of Nursing Leaders, have published best practices to help support the development of CNOs and other nurse leaders (American Organization of Nurse Leaders, 2023); however, not all leaders receive such training and resources. Within a local Mountain West health system, eleven new CNOs have received minimal formal training for their roles, resulting in a potential for underperforming in their responsibilities relative to receiving an optimal onboarding process. The stakes are high for ensuring success of these CNOs in facilities that employ over eight thousand nurses and care for thousands of patients each year. Available Knowledge Researchers have well documented the role of the CNO in building a thriving culture for nurses to practice and for patients to receive care (Bernard, 2021; Kauffman & Aucoin, 2021). The CNO is in a position of influence in the organization and can lead programs that are focused on evaluating equity disparities and social determinants of health (SDOH) in our communities and consequently positively impact the patients we care for. Ensuring that caregivers are prepared to address the screening, care and treatment of all patients equitably and holistically 5 begins with clear direction from the CNO and through policies that support incorporating the needs into the care plan (National Academies of Sciences, Engineering and Medicine, 2021). Despite the knowledge of the CNO’s critical impact on the organization, information on retention methods for nurse leaders is scarce and few articles contained information on a specific intervention for new CNO onboarding. In 2013, the American Organization for Nurse Executives (AONE) conducted a study and reported that 41% of CNOs planned to leave the role in the next three years and 67% planned to leave within five years (Batcheller et al., 2019). In 2023, a repeat survey indicated 15% of CNO’s planned to leave their role within six months, with the most common reason of their work adversely impacting their health and well-being (AONL, 2023). In other recent literature, turnover continues to be cited as an ongoing challenge, with “recent voluntary and involuntary turnover estimated to reach 67%” (Bernard, 2021). In a study from 2021, Bernard determined a relationship between job satisfaction and turnover intention, and ultimately the intent of leaders to vacate the role. Bernard (2021) also determined resilience is a critical factor in CNO job satisfaction. LeJeune (2023) found during his integrative review; the literature highlighted a standardized orientation program for new nurse leaders increased their engagement. Nurse leadership engagement can in turn directly influence the engagement of nurses providing direct patient care (LeJeune, 2023). Ramseur et al. (2018) states an important consideration when preparing nurse leaders is the knowledge that just serving in a leadership role does not automatically develop competencies necessary to be successful in meeting organizational goals. A responsibility of the organization is to provide a structured onboarding and orientation program to help novice senior nurse leaders (Kauffman & Aucoin, 2021). 6 Rationale The Johns Hopkins Evidence-Based Practice (JHEBP) Model for nurses and healthcare professionals is a model that helps to review, analyze, and translate scientific evidence (Dang et al., 2022). The application of the JHEBP model to this DNP scholarly initiative facilitated a clear and defined transition through each step in the process. Dang et al., (2022) describes the process: • In the inquiry step, a needed change is identified. For this project at a local health system, no CNO orientation program exists, and deficits in patient and organizational outcomes are possible. • Step two, determine the practice question. Does a formal orientation and onboarding process increase the knowledge and confidence of the chief nursing officer with less than eighteen months of experience in the role? • Step three, evaluate the evidence through a literature review and synthesis of the findings. In this step, a table of evidence was created for the topic focusing on confidence, knowledge, attitudes, competence and job satisfaction of nurse executives. • In the translation step, the evidence is evaluated for opportunities and best practices. Themes were identified to support development of the intervention. • In step five, developing best practices for implementation involved creating interventions for the CNO orientation toolkit, processes and methodology. • In the practice improvement step, interventions identified for the CNO orientation were implemented. • In the final step, the plan, do, study and act (PDSA) cycle is repeated as the process is evaluated and revised until objectives are met or next steps are 7 identified. This step was crucial to developing orientation resources that were useful and sustainable for new CNOs. Feedback was obtained from participants through mid-implementation interviews and a post-implementation survey. Specific Aims The purpose of this Doctor of Nursing (DNP) initiative was to enhance the knowledge and competency of new chief nursing officers within a local healthcare system through the development and implementation of an evidence-based leadership program, including training, a toolkit, and customized resources. The secondary purpose of this initiative was to evaluate and improve the leadership program based on participant feedback. This included measuring participant training completion rates, learning outcomes, and satisfaction to assess project feasibility. Methods Context This initiative took place in eleven hospitals in the Mountain West, including academic, trauma, community and critical access facilities. These facilities are located within rural, suburban and urban communities across Northern, Central and Southern Utah. The care sites are associated with an integrated health system, which includes acute hospitals, ambulatory clinics, outpatient surgery centers, an insurance company, home health and medical transport services. The administrative suite of the hospital functioned as the project site and involved the CNO for the facility. Each facility has one CNO that participated in the project for a total of eleven leaders. Leaders selected to participate were those with less than eighteen months in their current role, however several leaders had previous CNO experience. In many of these facilities the administrative team consists of three main leaders: a hospital president, chief nursing officer 8 and chief medical officer. Each facility has a different pre-existing culture and the CNOs have varying employee engagement scores despite working for the same health system with a standardized approach to pay, benefits and staffing. Designing a program that will be costconscious for the organization is a requirement considering the financial strains for health systems today. The number of nurses in the facilities ranges from as low as 30 nurses to as many as 2,000 per site, with a total number of nurses employed at the sites equaling approximately 8,000 nurses. These facilities combined care for thousands of inpatients and over a million outpatients each year. The CNO role is pivotal in achieving equitable patient outcomes, driving compliance for screening and following up on social needs identified for patients cared for in hospitals to improve health beyond acute episodic events. The training addressed a more sophisticated approach to addressing equity based on evidence. As nurse leaders are exposed to data on equity disparities and best practices for what can be done to improve health outcomes, we will begin to see a real change in the health of communities we serve. Outside of normal business operations, one CNO participant in this cohort was simultaneously participating in an executive development course sponsored by the company. Other initiatives were not taking place that would compete with the focus on this development opportunity. Intervention(s) This initiative to enhance the knowledge and competency for new chief nursing officers was approved for implementation as a quality improvement project by the Institutional Review Boards (IRB) of the project organization and the DNP student’s university. In phase one of the 9 project two surveys were carried out: a pre-implementation survey and a nurse executive competency survey. The pre-implementation survey was a series of questions with ratings on a Likert scale focused on attitudes, knowledge, competency and stress related to the role (Appendix A). The competency survey was a series of 30 questions focused on knowledge of topics ranging from finance to transformational leadership (Batcheller et al., 2019; Pedersen et al., 2018) (Appendix B). The questions were like those found on a nurse executive certification exam. In phase two, a series of seven hour-long development sessions were held weekly (Ramseur et al., 2018). They contained elements of different learning styles, including interactive discussion, videos, integration of humor and check points to determine assimilation of the information. The development sessions were created within the framework of the AONL Nurse Executive Competencies and five core domains and included the following topics (American Organization of Nurse Leaders, 2024): • Session one: Introduction, regulatory and hospital operations (Winstead & Moore, 2020) (Appendix C). • Session two: Emergency and capacity management, equity and healthcare ethics (Appendix D). • Session three: Healthcare finance; payers and government programs (McGarity et al., 2020) (Appendix E). • Session four: Operational and cost management strategies (Appendix F). • Session five: Revenue and patient throughput strategies (Appendix G). • Session six: Transformational leadership (LeJeune, 2023) (Appendix H), leading across the generations and adaptive leadership. 10 • Session seven: Strategic planning, servant leadership, efficiency practices, reflection and sharing (Appendix I). Finance session content was developed in collaboration with the Region Associate Chief Nursing Officer and Region Finance Director, who has extensive experience in healthcare finance and assisted with instruction, mentoring and discussion. Sessions were informed from literature reviews of evidence, informal discussions with facility nurse leaders, project content expert, pre-intervention survey, and scheduled with assistance from a region senior executive assistant. Participants were encouraged to attend all sessions. Sessions were held virtually and were recorded for later viewing. During phase three, mid-implementation of the program, PDSA cycles were initiated by interviewing each participant using a formal set of questions (Appendix J) for feedback on the course content and summarized resources in a CNO orientation toolkit (Appendix K). In this phase, information collected was used to improve future sessions and toolkit content (Kauffman & Aucoin, 2023). Current coaching, formal mentoring, and senior leader shadowing opportunities were also discussed with results recorded (Lawson, 2020). Phase four of the project included repeating the implementation survey with additional questions to collect feedback and satisfaction with the course (Batcheller et al., 2019) (Appendix L). The information obtained from the survey and course feedback was used to improve the content of the program and determine feasibility and usability of the program for new leader onboarding. Finally, an executive summary was created and submitted to the implementation organization (Appendix O). 11 Study of the Intervention(s) The project was expected to lead to outcomes of enhanced knowledge and leadership among novice CNOs. To accomplish this, the primary approach for assessing the impact of the interventions was through participants completing assignments throughout the implementation period demonstrating application of the principles discussed in the sessions, as well as a midimplementation interviews with participants to obtain feedback on improvements for the program. Interviews consisted of 30-minute sessions, held individually, to capture feedback and personal development needs. Following the interview sessions, communication updates were sent out to participants regarding the feedback provided and revisions were made to the content and delivery methods. Pre- and post-implementation surveys on confidence, stress and attitudes (Appendix A) as well as a survey measuring competency (Appendix B) related to content to be covered in the program were administered to assess the program’s impact, including feasibility, usability and satisfaction. The pre- and post-intervention surveys were used to determine that participant responses and increased competency were a result of the interventions. No other development interventions focused on content specific to the hospital CNO role occurred during the implementation timeline. Communication with the participant cohort occurred frequently throughout implementation and post-implementation to share results, outcomes, and the future of the program. Measures The pre- and post-implementation survey (Appendix A) consisted of seven demographic questions, eleven five-point Likert questions with a scale of strongly disagree to strongly agree, one multiple choice question about time desired to stay in the role, one open-ended question 12 about one thing they would want for their role, and one question to identify the barriers limiting the participant to excel in the role. The pre-implementation competency survey (Appendix B) was a thirty-question assessment with a focus on core competencies defined by AONL for executive leaders. The six domains have been compiled through subject matter experts and approved by the AONL Board of Directors. According to AONL (Hughes et al., 2022), these competencies can be incorporated into functional assessments, and orientation programs for traditional, new and emerging leaders. The competency questions were a combination of multiple choice with four or five response alternatives, and true/false, with correct responses calculated as a percentage of total questions. Following the recommendation of content experts, assignments were created to support the participants in applying the training principles to their practice, with content that included: • Completion of a hospital chain of command document, template provided (Appendix M). • Completion of a hospital staffing surge procedure, template provided (Appendix N). • Mid-Implementation interviews with formal questions (Appendix J). The assignments were given following the presentations during three out of the seven sessions. Participant responses were collected, reviewed and participants received feedback. As a process measure for feasibility, the percentage of participant completion of these assignments was measured. The mid-implementation survey (Appendix J) included six questions on what the participants like most about the program, what changes they would recommend, included a 13 reflection about application of principles, formal mentor relationships, and growth opportunities they would like for the future. The post-implementation survey (Appendix L) included the same pre- and postcomparison questions from the pre-survey, and included seven feedback questions, both qualitative and quantitative, to help evaluate the program’s feasibility, usability and satisfaction. Four Likert questions with a scale of strongly disagree to strongly agree asking about recommending the program to others, the content and presentation of the materials; three openended questions about what they liked the most and what they would recommend changing were included. Although the questions were like others in the literature, no single survey tool existed that would fit the content and competencies for this specific initiative. Time for each participant will be tracked and include time spent engaged in competency sessions, assignments, and reviewing other resource materials as a process measure for evaluating the feasibility and usability of the program. Analysis This DNP initiative utilized descriptive statistics in the form of qualitative and quantitative data throughout all phases of the project to help determine feasibility and usability. A comparison of paired quantitative data from the pre- and post- implementation attitudes, stress and competency surveys were analyzed using the Wilcoxon Signed-Rank (alpha 0.05) to identify statistically significant changes and the Pearson's r as a measure of effect size. Findings from this data informed content for the summary, interpretation, conclusions and future opportunities for enhancement. Qualitative data was also collected in the post-implementation survey in the form of open-ended questions. The open-ended questions were reviewed in detail, categorized and summarized with trends and common themes identified. Five-point Likert questions were 14 analyzed using descriptive statistics to assist in quality improvement processes and modifications for the program. Descriptive statistics were used to describe demographic information of the participants to be used in the analysis. Mid-implementation, semi-structured interviews were conducted with each participant to obtain feedback on the toolkit, the orientation process, and the program in general. Interview sessions were recorded with participant consent. Questions were open-ended and answers were documented during the interviews. The responses for each question were carefully analyzed, categorized and summarized. During project implementation, tracking of assignments occurred to show engagement and application of principles. Assignments were categorized in a bimodal format with “yes” or “no” based on completion, and feedback was provided on the content. Descriptive statistics were used to analyze and summarize the data collected. Ethical Considerations This Doctor of Nursing Practice (DNP) initiative was classified as a quality improvement project and therefore did not require oversight from the institutional review boards of Intermountain Health or the University of Utah. There were no conflicts of interest concerning this project. The DNP student had a direct supervisory relationship with many of the participants. Accordingly, the voluntary nature of their participation in the project was clearly conveyed. Participant responses were kept confidential, and some of the trainings were provided by individuals other than the DNP student. Results Demographics 15 There were eleven CNO participants in the program. Participants were master’s degree prepared between 35 to 55 years of age, 55% were female, 45% were male, and were primarily white (90.9%). All CNOs were less than eighteen months in their current role, with 36.4% having less than six months’ experience in the role (Table 1). The engagement of participants was measured through attendance at the seven sessions, completion of pre- and post-surveys and completion of two application of principles assignments. Overall engagement was high: participants attended sessions with an average of 82%, ten of eleven participants completed the application assignments, and 100% completed the pre- and post-survey. Competency Evaluation A thirty-question competency survey was administered both before and after the intervention, with questions based on the session content. Participants had an average 18% increase in post-intervention performance from 62% to 80%. Comparative Analysis Of the eleven participants, all eleven completed both the pre- and post-intervention surveys. The pre- and post-intervention survey analysis suggested statistically significant increases with medium to high effect sizes in four areas: post-intervention perceptions in confidence and knowledge of the hospital CNO role (p=.020, r=.703), barriers limit me to excel in my role as a CNO (p=.023, r=.685), resources needed to fully succeed as a CNO (p=.034, r=.640), and awareness of resources available that can help manage job stress (p=.046, r=.603). There were no statistically significant differences in perceptions of receiving orientation necessary to succeed as a hospital CNO, I feel prepared to fulfill my role as a CNO, I feel supported by my hospital leadership team, I feel supported by region leadership, I plan to stay in 16 my role as a CNO, I enjoy the work I do as a CNO, I have spent time sharing with my peers, and the amount of stress I feel is reasonable for the job (Table 2). In the survey, there were two, select-all that apply questions both pre- and postintervention. On the question, barriers limiting your ability to excel as a CNO, a total of twentyfive items were selected pre-intervention, and on the same question post-intervention, the total barriers dropped 52% to twelve items. On the question, the area of competency I feel least prepared for in the CNO role, sixty-two skills were selected pre-intervention, and dropped 39% to thirty-eight skills post-intervention (Table 3). Comments The post-intervention survey included three qualitative, open-ended questions: what aspects of the training participants found most beneficial, what modifications they would suggest, and examples of how they have implemented the principles learned. Participants valued the comprehensive overview of a spectrum of topics, peer CNO support during the sessions, and the resources provided. Participant suggestions for changes included more focused time on financial concepts, providing sessions in-person for more interaction with peers, and a longer orientation program. Feedback included, “I felt like it was over too soon. I wanted it to continue because I appreciated the content and the collaboration with other CNOs.” Participants applied the content as they shared with other nurse leaders in their organization and through completing assignments. One participant shared, “The program brought forward gaps in my current knowledge and supported my development as a CNO. I enjoyed the time with peers and loved brainstorming how we can solve issues together.” Mid-implementation mentor and feedback sessions were held individually with each participant. Feedback was used to determine what was working well and to revise the program. 17 Several improvements were made because of these interviews and in weekly sessions through the PDSA process which included revising the content for the remaining sessions, adjusting the cadence of the information presented, and including more guest presenters. Feasibility and Usability Post-intervention feasibility questions included recommending the program (1 agree, 10 strongly agree), I learned something new (1 agree, 10 strongly agree), materials were presented in an understandable way (1 agree, 10 strongly agree), and the objectives of the program were met (1 agree, 10 strongly agree) (Table 4). During the mentor sessions, I noted trends in comments were very favorable on the format of the program, involvement, application of principles and ease of resources available (including the toolkit). The program cost was minimal. The cost of the salaries for mentor time was figured by taking the time for preparation, creating resources, tools and materials for the program and multiplying it by an average hourly rate of the leaders. The cost of the salaries for each CNO participant included total hours in competency sessions, completing assignments, pre and post implementation, participant PDSA interviews, and then multiplying them by the average hourly rate for CNOs. No additional incremental costs were associated with this project due to the virtual nature of the training, and platforms and resources were already available within the organization. An executive summary was created and shared with key stakeholders (Appendix O). Discussion Summary The intervention was conducted as planned, with adjustments made through the PDSA cycle. The results indicate that although hospital CNOs did not perceive every aspect of the 18 program as significantly impacting their preparation and overall stress as a CNO, the program likely enhanced the leaders’ confidence and knowledge and mitigated barriers to performing in the role post-intervention. In addition, all leaders found participating in the program valuable. Interpretation The results are consistent with other evidence-based orientation and development programs and align with expected outcomes. After completion of the program, participants likely felt more confidence and knowledge in their role. This finding was a desired outcome from this initiative and supports the processes and tools implemented. Other nurse leader training programs described in the literature produced similar outcomes (Batcheller et al., 2019; Winstead & Moore, 2020) following the implementation of an orientation program, “the CNO Academy developed to provide new and aspiring CNOs with foundational role competencies was shown to be highly effective” (Batcheller et al, 2019). CNOs suggested experiencing fewer barriers in their role after participating in the initiative, with improved understanding of and access to the resources they need to succeed. In the survey question about barriers to succeed in the role, CNOs pre-intervention selected training and orientation, development and growth opportunities, and mentorship growth as barriers, while post-intervention these items were no longer seen as a barrier. In addition, participants knowing what resources were available and where to locate those resources for future reference was a satisfier in the program. These findings may suggest that resources provided in the CNO training program reduced the barriers associated with their role. Ramseur et al. (2018) found similar success in a formal orientation program, including mentor relationships, and resulted in fewer barriers to CNO success. 19 Results showed participants improved their performance by nearly 20% on the competency exam post-intervention. These results suggest attendance at the program sessions increased knowledge about key competencies of the CNO role. A Nurse Leadership Development Program (NLDP), developed in a similar health system, demonstrated “the NLDP survey results indicate that 100% reported their knowledge of nursing leadership increased” (Ramseur et al., 2018). Participants applied the principles through developing guidelines that were lacking at their care site for chain of command escalation, creating greater clarity for nurses working in the organization. This outcome may reinforce the importance for CNOs to implement a clear escalation pathway plan as a means for fostering safe work environments. Other research similarly shows patient safety outcomes are impacted by communication gaps, and policies that promote a culture of safety are top of the list of accountabilities for healthcare leaders, including a clear organizational chain of command (Sculli et al., 2015). A ceiling effect was experienced with several of the questions, including CNOs feeling supported by local and regional leadership partners pre- and post-intervention. Of little surprise was response on the question, “the amount of stress I feel is reasonable for the job” having no change in the pre- and post-intervention scores, as I did not specifically focus on resilience and how to cope with challenge stressors (workload, work pace, time pressures, tax complexity) in the program. Most research on leader orientation programs did not specifically study if the initiative had an impact on job role stress, however, one article that focused solely on resilience education for nurse leaders showed a reduction in work stressors (Rosa-Besa et al., 2022). Determining the value of investment (VOI) for this DNP initiative included evaluating outcomes related to the level of knowledge and competency of leaders in the organization in 20 addition to the costs and benefits of the proposed intervention compared to alternatives or experiencing turnover in the role. The costs for mentor and CNO participant salaries were minimal. No additional incremental expenses were associated with this project due to the virtual nature of the training, as the necessary platforms and resources were already available within the organization. The Center for American Progress (Boushey & Glynn, 2012) studied turnover over two decades from research studies and estimates that the cost of executive level leadership turnover is up to 213% of an annual salary, significantly higher than that of a frontline employee. In Utah, the average annual salary for CNO is $249,540 (salary.com, 2024). Organizations who lose a CNO require an interim leader, either internal or external, which adds cost to the turnover process. The overall VOI was positive considering the minimal cost of investment and high cost of potential turnover. While there is likely to be an additional impact of CNO turnover on the nursing workforce, quantifying a value as a direct result has not been determined in the literature. Limitations The small sample size of eleven participants was a limitation to generalizing results to other health organizations. Findings and outcomes may have been impacted by the leaders receiving the orientation after being in their CNO role, in some cases up to eighteen months, as lived experience can bias reactions to the questions about initial orientation and overall impact of the program. In addition, many CNOs had a direct reporting relationship with the student conducting the initiative, which may have created some direct or inherent bias. Attempts were made to mitigate the impact of this relationship by upfront communication of freedom from any implications to job performance through participation in the program and by having guest presenters for much of the content. Finally, the length of the orientation was limited by the length 21 of the scholarly initiative timeline. Future cohorts would benefit from extending time for more in-depth discussion and individual assessments of the leader in areas of emotional intelligence, personality, and behaviors to create a personalized development plan. Conclusions The program was considered successful, with participants reporting satisfaction, and will be sustained by adopting it to help orient future novice CNOs in the health system. The program’s success may support modifying the content for other roles and settings, and it is recommended that additional cohorts be implemented in other regions of the organization, and that an orientation program for the nurse director position be evaluated. When building content for future cohorts, one should consider more focused time on financial concepts, providing more in-person sessions, and a longer orientation program. Given the limited number of executive positions hired in any health system, it is imperative to establish mechanisms for connecting leaders to peer support throughout this process. Future applications should consider the participants’ desire to be part of a cohort of leaders who are learning, growing, and developing together. 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The relationship between resilience, job satisfaction, and anticipated turnover in CNO’s. www.nurseleader.com. Boushey, H. & Glynn, S. (2012). There are significant business costs to replacing employees. Center for American Progress. https://www.americanprogress.org/article/there-aresignificant-business-costs-to-replacing-employees/. Dang, D., Dearholt, S., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins EvidenceBased Practice For Nurses and Healthcare Professionals, Fourth Edition. Sigma Theta Tau International Honor Society of Nursing. Huges, R., Meadows, M.T., & Begley, R. (2022). AONL nurse leader competencies: core competencies for nurse leadership. www.nurseleader.com. https://doi.org/10.1016/j.mnl.2022.08.005 Kauffman, S., & Aucoin, J. (2023). Building a transition program for senior nurse leaders. Journal for Nurses in Professional Development, Vol. 39, No. 1, 12-17. DOI: 10.1097/NND.0000000000000781. 23 Lawson, C. (2020). 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A nursing leadership immersion program: succession planning using social capital. The Journal of Nursing Administration, Vol. 48, No. 3, pp 168-174. DOI: 10.1097/NNA.0000000000000592. Ramseur, P., Fuchs, M., Edwards, P., & Humphreys, J. (2018). The implementation of a structured nursing leadership development program for succession planning in a health system. The Journal of Nursing Administration, Vol. 48, No. 1, pp 25-30. Rosa-Besa, R., Graboso, R., Soledad Banal, M., Malpass, A. (2022). Work stress and resiliency of nurse leaders. The Journal of Nursing Administration, Vol. 52, No. 10, October Supplement 2022. 24 Salary.com. (2024, November 1). Chief nursing officer salary in the United States. https://www.salary.com/research/salary/alternate/chief-nursing-officer-cno-salary Sculli, G., Fore, A., Sine, D., Paull, D., Tschannen, D., Aebersold, M., Seagull, F.J., and Bagian, J. (2015). Effective followership: a standardized algorithm to resolve clinical conflicts and improve teamwork. American Society of Healthcare Risk Management, Vol. 35, No. 1. DOI:10.1002/jhrm.21174. Winstead, J., & Moore, C. (2020). Outcomes and impact of a nursing regulatory orientation workshop for nurse leaders. Journal of Nursing Regulation, vol. 10, Issue 4. http://www.journalofnursingregulation.com. 25 Tables and Appendices Table 1. 26 Table 2. 27 Table 3. 28 Table 4. 29 Appendix A Pre- and Post-Implementation Survey Questions Demographic Questions: 1. Do you think of yourself as: a. Male b. Female c. Non-binary/ third gender d. Prefer not to answer 2. Are you of Hispanic, Latino or Spanish origin? a. Yes b. No c. Unknown d. Prefer not to say 3. How would you describe yourself? a. American Indian or Native American b. Asian c. Black or African American d. Native Hawaiian or Pacific Islander e. White f. Other Race g. Unknown h. Prefer not to say 4. Age: a. <18 years b. 18-24 years c. 25-34 years d. 35-44 years e. 45-54 years f. 55-64 years g. 65-74 years h. >75 years 5. Number of months in current role: a. 1-6 months b. 7-12 months 30 c. 13-18 months d. 19-24 months e. >24 months 3. Total years as a nurse leader (manager or above): a. 1-5 years b. 6-10 years c. 11-15 years d. 16-20 years e. >20 Years 4. Highest level of education completed: a. Master’s Degree b. Doctorate Degree Survey Questions: 5. I received the orientation necessary to succeed in my role as a hospital chief nursing officer (CNO). a. Strongly Disagree b. Disagree c. Neutral d. Agree e. Strong Agree 6. I am confident in my knowledge of the role of a hospital chief nursing officer (CNO). a. Strongly Disagree b. Disagree c. Neutral d. Agree e. Strong Agree 7. I feel prepared to fulfill my role as hospital chief nursing officer (CNO). a. Strongly Disagree b. Disagree c. Neutral d. Agree e. Strong Agree 8. I feel supported by hospital leadership in my role as a CNO. a. Strongly Disagree b. Disagree c. Neutral d. Agree e. Strong Agree 31 9. I feel supported by regional leadership in my role as a CNO. a. Strongly Disagree b. Disagree c. Neutral d. Agree e. Strong Agree 10. I plan to stay in my role as hospital chief nursing officer (CNO) a. < 1 year b. 1-3 years c. 3-5 years d. >5 years 11. Barriers limit me in my ability to excel in my role as a CNO. a. Strongly Disagree b. Disagree c. Neutral d. Agree e. Strong Agree 12. What barriers limit your ability to excel as a CNO? [select all that apply] ______ Difficulty/scope of the role ______ Relationship with my leader ______ Resources and support provided for the role ______ Relationship with other members of the hospital administrative team ______ Teamwork and collaboration between members of my team ______ Training/orientation provided ______ Increasing demand/complexity of responsibilities ______ Support from Intermountain senior executive leaders ______ Development/growth opportunities ______ Mentorship/growth opportunities ______ Other________________________________________________________ 13. I have the resources I need to fully succeed as a CNO. a. Strongly Disagree b. Disagree c. Neutral d. Agree e. Strong Agree 14. I enjoy the work I do in my role as a hospital CNO. a. Strongly Disagree b. Disagree c. Neutral d. Agree e. Strong Agree 32 15. The area of competency I feel least prepared for in my hospital CNO role is [select all the apply]. a. Regulatory requirements b. Financial acumen c. Caregiver engagement d. HR/Labor relations e. Emergency management f. Healthcare Ethics g. Coaching/mentoring h. Medical Staff rules/regulations i. Governing Boards j. Utah State laws/Utah Board of Nursing k. Transformational leadership l. Strategic Planning m. Business Plans/Proposals n. Presenting in front of teams o. Time management/organization p. Executive presence q. Emotional intelligence in Leadership 16. If I could wish for one thing I don’t currently have in my role, it would be_________________________________________________________________. 17. I have spent individual time with my CNO peers sharing best practices related to the role. a. Strongly Disagree b. Disagree c. Neutral d. Agree e. Strong Agree 18. The amount of stress I feel is reasonable for the job. a. Strongly Disagree b. Disagree c. Neutral d. Agree e. Strong Agree 19. I am aware of resources available that can help me manage my job stress. a. Strongly Disagree b. Disagree c. Neutral d. Agree e. Strong Agree 33 Appendix B Nurse Executive Competency Assessment 1. Union-organizing activities are occurring at an institution. According to National Labor Relations Board regulations, the institution's management may: A. Distribute information to workers about the union's record on dues, strikes, and other aspects of its performance. B. Offer additional insurance coverage while the organizing activities are taking place. C. Provide an unscheduled wage increase while the organizing activities are occurring. D. Restrain the union-organizing committee from soliciting authorization cards. Answer: A 2. A healthcare organization is the focus of a union-organizing campaign. The nurse executive responds by: A. Attending the union's organizational meetings to better understand the employees' needs and concerns. B. Engaging staff in a discussion about the union campaign. C. Helping staff members who oppose unionization to determine their next actions. D. Providing factual information about the union, if an employee asks. Answer: D 3. Research suggests that the nurse executive most effectively improves employee job satisfaction by: A. Increasing employee salaries. B. Increasing staff autonomy. C. Offering more educational assistance. D. Providing a clinical advancement program. Answer: B 4. A 14-year-old patient, a practicing Jehovah's Witness, is admitted for anemia. The physician determines that blood transfusions are necessary, but the patient's parents refuse to consent. The patient states that they wish to be treated. The nurse executive's action is to: A. Contact local clergy for assistance in crisis intervention. B. Inform the patient that their parents must consent before treatment can be administered. C. Inform the patient that they are a minor and incapable of such decisions under state law. D. Request that the administration contact the hospital attorney for legal counsel. Answer: D 34 5. Which percentage of employees must vote for union representation before the union can be certified as an official bargaining agent? A. One half or 50% of the employees who vote, plus one employee. B. One half or 50% of the total number of employees, plus one employee. C. Two-thirds or 67% of the employees who vote. D. Two-thirds or 67% of the total number of employees. Answer: A 6. To address high turnover and low job satisfaction among nurses who have worked at the hospital for five years or more, the advanced nurse executive develops an action plan that includes: A. Discontinuing the career ladder, as it is costly and has been ineffective in retaining staff. B. Eliminating sign-on bonuses for nurses who are joining the organization. C. Increasing recruitment efforts to replace nurses who are leaving. D. Working with temporary staffing agencies to ensure adequate unit coverage. Answer: B 7. When managing conflict, how does the nurse executive lead by example? A. By discouraging differences. B. By evaluating and initiating immediate action. C. By identifying past experiences with conflict. D. By recognizing and accepting feelings. Answer: D 8. Which ethical conflict places equitable access to health care against actions that produce the greatest good? A. Autonomy versus paternalism. B. Fairness versus altruism. C. Justice versus utilitarianism. D. Veracity versus fidelity. Answer: C. 9. With Medicare, the benefit period ends: A. 60 days after discharge from the facility. B. 30 days after discharge from the facility. C. At the time of discharge from the facility. D. 150 days after discharge from the facility. Answer: A. 35 10. Which of the following terms refers specifically to the process by which a person is granted authority to practice in an organization? A. Licensing B. Privileging C. Credentialing D. Certifying Answer: B 11. The Joint Commission’s Environment of Care requires management plans for which functional areas? A. Safety, security, hazardous materials and waste, fire safety, medical equipment, and utilities. B. Pharmacy, medical equipment, ventilation, hazardous materials, and waste. C. Infection control, fire safety, discharge planning, security, and technology. D. Infection control, safety, security, ventilation, pharmacy, and medical equipment. Answer: A. 12. The advanced nurse executive develops a balanced scorecard for nursing practice by emphasizing: A. Consistency over time. B. Customer feedback. C. Financial performance. D. Internal and external benchmarks Answer: D 13. When providing administrative oversight for a telehealth program, the advanced nurse executive's legal-ethical concern is: A. That telehealth eliminates the risk of a breach of patient information. B. The competence of a nurse in another jurisdiction. C. Whether telehealth nurses are protected from litigation under case law. D. Whether the scope of practice is limited by the state where the telehealth site exists. Answer: D 14. When an insurance plan negotiates a specific fee for a procedure (including all charges) and pays one bill, this is referred to as: A. Fee for Service B. Bundling C. Discounted Fee for Service D. Value Based Care Answer: B 36 15. The primary core criteria for medical staff credentialing and privileging are: A. Licensure, education, quality of care, and clinical knowledge B. Licensure, education, communication skills and professionalism C. Licensure, education, competency, and performance ability D. Licensure, education, clinical knowledge, and systems knowledge Answer: C. 16. The following are functions of a governing board: A. Appoint members of the medical staff B. Appoint the chief executive officer C. Patients are admitted by a qualified medical provider D. Ensure the chief nursing officer is qualified for the role E. A, B, C only F. B, C, D only Answer: E. 17. Each facility in Intermountain Health is required to have an emergency preparedness policy that follows the ____________ guidelines. A. Federal Emergency Management Agency (FEMA) B. Department of Health and Human Services (HHS) C. Centers for Disease Control (CDC) D. National Incident Management System (NIMS) Answer: D. 18. The following are components of an Incident Command System EXCEPT: A. Command B. Operations C. Leadership D. Planning E. Finance Answer: C. 19. I know the first steps to take when setting up an Incident Command Center for my facility. A. Yes B. No C. Not sure 20. The Utah Board of Nursing is the governing body that sets minimum requirements for nursing school standards in Utah. A. True B. False 37 Answer: False 21. The Utah Nurse Practice Act contains the following: (select all that apply) A. Education, examination, and licensure requirements B. LPN, RN and APRN scope of practice C. Membership composition for the board of nursing D. Defines unprofessional conduct Answer: A, B, C, D 22. Which of the following elements are part of the CMS Prospective Payment Systems (pay for performance) programs? A. Mortality, complications, patient experience and patient safety B. 30-day readmissions, WPV, HAC rates, and mortality C. HAC rates, patient safety, mortality and caregiver injuries D. WHPUOS, mortality, complications, and patient experience E. Patient experience, patient safety, mortality, and compliance Answer: A 23. Examples of variable costs in healthcare include (select all that apply): A. Direct patient care hours B. Utilities C. Patient care supplies D. Rent or lease expenses Answer: A & C 24. What are the 2 key drivers impacting your WHPUOS calculation? A. Total department staff worked hours & length of stay B. Volume & bedside staff worked hours C. LOS & midnight census D. Total department worked hours & patient volumes Answer: D 25. The following are characteristics of transformational leadership EXCEPT: A. Offer promotional opportunities to followers who perform at high levels. B. Stimulates and encourages followers to challenge their own beliefs. C. Have a strong set of values and act toward the greater good of the team. D. Communicate high expectations to followers inspiring them to achieve organizational goals. Answer: A 38 26. Research has shown transformational leaders use four common strategies. These include (select all that apply): A. Developing trust B. Have a clear vision for the future C. Are social architects for the organization D. Have positive self-regard Answer: A, B, C, D 27. A weakness in transformational leadership is the lack of defined parameters and conceptual clarity. A. True B. False Answer: True 28. CMS conditions of participation require that each patient have a care plan and must be separate from the interdisciplinary plan of care. A. True B. False Answer: False 29. CMS conditions of participation do not allow a patient’s own meds to be brought into the hospital. A. True B. False Answer: False 30. According to CMS, restraints include surgical bandages, orthopedic devices and helmets. A. True B. False Answer: False 39 Appendix C: Session 1 40 41 42 43 44 45 46 Appendix D – Session 2 Content 47 48 49 50 51 52 Appendix E- Session 3 Content 53 54 55 56 Appendix F- Session 4 Content 57 58 59 60 Appendix G – Session 5 Content 61 62 63 Appendix H- Session 6 Content 64 65 66 67 68 69 70 Appendix I- Session 7 Content 71 72 73 74 75 76 Appendix J Mentoring/Mid-Implementation Discussion Questions 1. What have you liked the most about the program thus far? 2. What changes would you recommend going forward? 3. Can you share one reflection you’ve had during the course of this program? 4. What additional growth and development opportunities are you interested in? 5. Do you have a formal coach/mentor? a. If no, would you be interested in having a formal coach/mentor? b. If yes, what do you find most valuable about that relationship? 6. What is your interest in job shadowing opportunities with senior executives in the organization? 77 Appendix K-CNO Orientation Toolkit This CNO toolkit is based on evidence-based practice (EBP) quality improvement and research completed on training, orientation and onboarding of nurse leaders.The elements are based on the American Organization of Nurse Leaders (AONL) Executive Nurse Competencies, EBP found to be most effective in the research, self-assessment and competencies that are crucial for the hospital nurse executive. AONL Nurse Competency Model The fundamentals covered in the orientation include: Leadership: transformational and servant leadership, innovation. Professionalism: social determinants and equity, governance. Communication & Relationship Management: effective communication, generational impacts, labor relations. Knowledge of the Health care Environment: regulations, quality and safety, CMS. Business Skills & Principles: finance, strategy, 78 Introduction: Intermountain Nursing Element Resource Intermountain Nursing Professional Practice Model National Certification Career Development - Professional Certifications Resources Nursing Bundle Elements Nursing Services - Nursing Bundle Professional Dress code Clinical Colors of Care ANCC Magnet & Pathways Resources Magnet and Pathway Programs 79 Intermountain Nursing Clinical Advancement Program -iAspire iAspire Nurse Professional Development Program Orientation Sessions Pre-work: Complete pre-orientation and competency surveys. !"#A%C'E)*%+",-.%C !"#$%&'#"(#&')*&+I'E/0N2%,%3+4C'E5AA%AAN%3,C'E6C'E!0C'E53A7%#A890+* ./"(#012*P4 In the first week listen the following: • AONL podcast: Nailed it! How Peer Mentorship Led to Successful CNO Transitions https://www.aonl.org/nursing-leadership-podcast Module 1 Competency: Knowledge of the Healthcare Environment Resource documents for module 1: Area of Competence Resource Presentation !"#$%CD(%D()*+,-. /MN2P4D-./5-./,#D%D(C6C$N(788C9 AONL Nurse Executive Competencies !"#A%#C'E)% *+),C-.L)%0NO3)-)4,.)E5367 CMS Conditions of Participation -Hospital Governing Body !"#$!BC$'()GH,-./$ M)1OP4,45$S)789H7: 80 CMS Conditions of Participation – Nursing Services CMS Conditions of Participation – Patient Rights CMS Conditions of Participation – Quality Improvement !"#$!%C$'()*+,-$ #.)/+M.*$NOP4 !"#$!%C$C'()*+($ ,)-.(/M1OP !"#$!%C$'()*+I-$ ./M1OPQ/Q5ISM78 2024 National Patient Safety Goals !"#$%&"'()"#$G&#( +",G#-(.%"'/(0N02P45, Utah State Inpatient Requirements !"#$%&"#"'%()*#"+')"% I'-.+/'0')"12*34 TJC Safer Infographic !"#A%& 'EF*+I-./012.3F Application of Principles Assignment: Complete chain of command documents if not updated within the past year. If it is already complete, review for accuracy and submit document(s). Templates are available below. !"#$%C'"()*C+,(-.( /-##C,0(,-,(/%+,+/C%(121340-/5 !"#$%&'"()*&+,(-.( )-##&,/($&'+",'()%+,+)&%(01023/-)4 Module 2: Knowledge of Healthcare Environment, Professionalism, Health Equity and Ethics 81 Topics: o o o o Medical Staff Emergency Management Healthcare Ethics Health Equity/SDOH Resource documents for module 2: Area of Competence Resource Presentation !"#$%C#D()*+,$%C -".$%C.D/*M,N,/(M$%CO(P45*$%C%677,8 Medical Staff !"#$!%C$"'()*+,$ #-+../M(. Utah Nurse Practice Act !"#A%&"#"'%()*+'% ,*#-".-'%/-"0N2P Preparing for Union Activity !"#A%"C'()*+"),'C+') !"#A%&"'()"*%+( -./C0C/1)%/)2+P")4%"#)5C/#)S7U79S7A:* ,-'"#A%&.(L0#N234 Emergency Management !"#$!%C'$ !"#$%#&'E) E)*+,*-./$C+*M1+*O-*PP4MO5 *$#+,$#-&#..)*/01'E2+-P !"#A%CD(A!FC*+I-I-C !"#$%&'()!*(+!%)(,$ F+I.L0CNOOIP0+C4+RL+.6CFRRT8IVC:;<=>O #+&-"+-&.$()/$.,.0.)+#12/3 Healthcare Ethics Hurricane Katrina Documentary: (45 minutes) https://www.youtube.com/watch?v=H3QmruFdfgo Hartford Health Incident Command Set Up (9:49 min.) https://youtu.be/MQFErLY6f3I IHI Health Equity Leadership Framework: (3:03 Min.) 82 https://youtu.be/WuMwRTjjgnI Health Equity Article: !"#AB"A#&'()&B*HI( &-K(/0&'"1(2-03A*"*0H(*-("10(4!R(S&*'07U(9#*0:0#(0"(&';<K= The Myth of Race Video: https://www.bbc.com/videos/cd733g7x4z4o Intermountain Security & Safety Guidelines !"#$%&'EFG+"F,-F./%#"F !"#A%&''E)**'+,E 0$&1"O&P"+FF4R'&"P'FSO/7"U"P'F9:;F9<<=;F>"?&+"1F@FAF=<=BC71-*%.'/0*'E12P4AE56576586#/1 Application of Principles Assignment: Create a surge and capacity management document for your facility to include the following components. Include: Hospital departments, types of patients cared for, overflow areas, hospital surge capacity areas and staffing. Locate and review your Emergency Management Plan. They are comprehensive documents that should look similar to the following: Module 3: Finance Training #1 Topics: o Finance definitions o Accruals o Staffing and volumes !"#$%&#'%()G+,"-.% )G+/010/#23)G+45,1#20&)G+2%61&02%7$5/8 !"#$%#C'E) *H#$,-./C0)1O,C)1P4)R#%./C6H78 83 Area of Competence Resource Presentation !"#$%C'(F*F+,$%C -./0NO.3$%C4,NN(.F$%C5S3378 Module 4: Finance Training #2 Topics: o Revenue streams & funding o Financial challenges o Strategies for financial sustainability Area of Competence Resource Presentation !"#$#%&'(F*+,-.&' (F/M1123 Module 5: Finance Training #3 Topics: o Revenue o Growth strategies Area of Competence Resource Presentation !"#$#%&'(F*+,-.&' (F/M1123 Module 6: Transformational Leadership Topics: o Transformational leadership o Generational support 84 Area of Competence Resource Presentation !"#$%C#D()*+,$%C -".$%C.D/*M,N,/(M$%CO(P45*$%C6788,9 Transformational Leadership resources Trust & Inspire- Stephen Covey Dare to Lead – Brene Brown Module 7: Servant Leadership/Strategy Topics: o Practical applications o Servant Leadership o Strategic thinking Area of Competence Resource Presentation !"#$%C#D()*+,$%C -".$%C.D/*M,N,/(M$%CO(P45*$%C6788,9 Request Access: Access Hub Request Home Servant Leader Resources Request co-pilot for Microsoft 360 Leaders Eat Last – Simon Sinek The Culture Code- Daniel Coyle 85 Intermountain Health Leader Resources Area of Competence Resource Intermountain Nursing website Nursing Services - Home Human Resources – Home - Workday Caregiver Engagement Survey- Home | Manager Assist Nursing Financial Spreadsheets Acute Care Nursing Benchmarking/Financials - 2025 - All Intermountain Policy Library Daily Huddle, Templates & Performance Boards- Policy Library - Home Workday Qualtrics CI Portal Payroll -UKG Documents CI Portal https://ihchealthservicessso.prd.mykronos.com/?tenantId=IHCHealthServices_prd_01 Recognition Portal Intermountain Patient Experience - XM Dashboard | Qualtrics Experience Management | Read Me Qualtrics 86 Finance Portal – Strata Login Nursing Quality Indicators- Insights Insights - Dashboards - Nursing Scorecard: Scorecard CMS SDOH Dashboard-Insights Barcode Medication Administration Dashboard- Insights Vizient Quality & Accountability Dashboard- Insights OSHA Recordable Injuries- Insights Patient FlowDischarge Barriers Dashboard- Insights Payroll Schedule Expense Management - Peoplesoft Insights - Dashboards - CMS Inpatient Screening (All Regions) Strata Insights - Dashboards - Barcode Medication Administration (Canyons & Desert) Insights - Dashboards - Vizient Q&A Performance Insights - Dashboards - OSHA Recordable Injury Dashboard (Canyons, Desert) Insights - Dashboards - Patient Flow - Discharge Barriers Tool Pay & Compensation - Payroll Calendar Expenses 87 Appendix L - Post Intervention Survey 1. I would recommend this toolkit, orientation and mentoring to other hospital new CNOs. a. Strongly Disagree b. Disagree c. Neutral d. Agree e. Strong Agree 2. I learned something new from participating in this program. a. Strongly Disagree b. Disagree c. Neutral d. Agree e. Strong Agree 3. The objectives of this program were met. a. Strongly Disagree b. Disagree c. Neutral d. Agree e. Strong Agree 4. Materials were presented in an understandable way. a. Strongly Disagree b. Disagree c. Neutral d. Agree e. Strong Agree 5. What I liked the most about this CNO orientation toolkit ________________________________________________________. 6. What I would change about this CNO orientation toolkit ____________________________________________________________________. 7. Please provide an example of how you applied content from this orientation in your leadership role. _____________________________________________________________________. 88 Appendix M - Chain of Command Template Chain of Command is to be used when concerns regarding a patient’s clinical status are unresolved. This guideline also addresses incidents when there is no response, if the response is inadequate or inappropriate, and establishes a process for taking further action until an acceptable resolution is reached. Follow the arrows based on patient presentation. Emergent - situations require immediate Code Blue or rapid escalation for physician/APP response. Urgent - situations in which the patient is deteriorating, and intervention is required (Rapid Response Team). Non-Urgent - A patient condition/situation where the patient is in no immediate danger. NURSE PHYSICIAN/APP CHARGE NURSE UNIT MANAGER/DIRECTOR RAPID RESPONSE TEAM HOSPITAL CNO AVP PRACTICE EXCELLENCE mg on call: Provider for Group/DEPT CHAIR mg HOSPITAL CMO Name Manager Director Dept. Chair Hospital CMO Hospital CNO AVP Practice Excellence Office # Mobile # 89 Appendix N - Hospital Surge Capacity Template 90 91 92 Appendix O Executive Summary Enhancing Competency and Performance: An Evidence-Based Leadership Initiative for Novice Chief Nursing Officers _____________________________________________________________________________________________ Situation: Within the health system, eleven new CNOs recently received minimal formal training for their roles, resulting in a potential for underperforming in their responsibilities relative to receiving an optimal onboarding process. The role of the CNO in the success of building a thriving culture for nurses to practice and for patients to receive care has been well documented. Failure to properly orient new CNO’s to succeed in these responsibilities can result in unstable clinical care environments, increased nurse turnover, significant financial and operational costs, and altered expectations and structures. The stakes are high for ensuring success of these CNOs in facilities that employ over eight thousand nurses and care for thousands of patients each year. The responsibility of the organization is to provide a structured onboarding and orientation program to help novice senior nurse leaders. Background: An orientation program was developed to enhance the knowledge and competency of new chief nursing officers through the development and implementation of evidence-based leadership concepts. The orientation included a series of seven weekly sessions covering content from the AONL Nurse Executive Competencies, assignments to create documents relevant to hospital and nursing operations, individual mentoring and PDSA session, and creation of a resource toolkit. Pre- and post-intervention surveys and a competency assessment were administered to determine efficacy of the intervention. Assessment: The pre and post intervention survey analysis suggested statistically significant increases with medium to high effect sizes in four areas: post-intervention perceptions in confidence and knowledge of the hospital CNO role (p=.020, r=.703), barriers limit me to excel in my role as a CNO (p=.023, r=.685), resources needed to fully succeed as a CNO (p=.034, r=.640), and awareness of resources available that can help manage job stress (p=.046, r=.603). Participants liked the broad overview of a spectrum of topics, peer CNO support during the sessions, and the resources provided. Participant trends for changes included more focused time on financial concepts, provide sessions in-person for more interaction with peers, and a longer orientation program. Financials: Determining the value of investment (VOI) for this DNP initiative included evaluating outcomes related to level of engagement and productivity of nurses in the organization in addition to the costs and benefits of the intervention compared to alternatives or experiencing turnover in the role. The costs for mentor and CNO participant salaries were minimal. The Center for American Progress estimates that the cost of executive level leadership turnover is up to 213% of an annual salary. In Utah, the average annual salary for CNO is $249,540. The overall VOI was positive considering the minimal cost of investment and high cost of potential turnover. While there is likely to be an additional impact of CNO turnover on the nursing workforce, quantifying a value as a direct result has not been determined in the literature. Cost-benefit of the intervention compared to no orientation Cost to the Organization Orientation Salary- Mentor Time $15,000 No Orientation 93 (50 hours X $150/hour) Salary- Participant Time $2,500 (20 hours X $125/hour) CNO Turnover $530,520 (213% annual salary) CNO Interim $124,770 (6 months salary) Potential cost savings for the organization $637,790 Recommendation: The program was considered successful and is recommended Intermountain Health continue with new CNO orientation. Tools and resources should be added online for ease of access. Minor adjustments should be considered to expand the content as indicated, including personalized assessments, and should be reviewed annually for revision of content.