When Ginger Irsik became administrator at Prattville (Ala.) Baptist Hospital after 12 years as a nurse, little did she know that her job would require her to oversee a major change in operations just one week into her new position when the hospital's elevators failed.
But Irsik sprang into action to ensure portable X-ray and EKG machines were in place, patient care was not disrupted and safety issues weren't being compromised. The administrator had to make sure clinical managers were communicating with engineers, while she made the decision to hold patients longer in the ground-level emergency room and recovery rooms of the two-story, 47-bed facility before moving patients to second-floor inpatient rooms. After making sure the hospital was operating efficiently, Irsik then had the elevators replaced.
"Can you imagine doing patient care without using elevators?" Irsik says. "It really emphasized how well our team works together."
Irsik is just one example of a new generation of healthcare executive: nurses who climb into the top leadership ranks. More nurses are making career moves to the corporate level, trading in their scrubs for business attire, balancing their foundation of patient care with the responsibilities of operating a hospital.
Irsik, who was the chief nursing officer before becoming administrator, is tackling the executive responsibilities at her hospital while pursuing a master's degree in business administration at Auburn University Montgomery (Ala.). She expects to earn her MBA within three years.
The American College of Healthcare Executives estimates that some 700 hospital chief executive officers and 540 chief operating officers started in the healthcare industry as nurses.
It is not an easy transition, nurse executives say, but they believe their experience working with patients brings a different perspective to the positions of CEO and COO that keeps quality of patient care as a top priority and focuses on leadership through team-building.
"Nursing executives have such a broad knowledge of the operations of a hospital," says Rita Turley, a consultant with the Robert Wood Johnson Foundation and president of her own consulting firm in Billings, Mont. "A hospital is functioning as a team. They have first-line experience in understanding those relationships."
Building strong relationships with other units in the hospitals is key to a successful career as an executive, Turley says. Nurses are generally more sensitive about the work conditions, especially what is happening at the bedside, making them prime candidates to become top-level executives because of their knowledge about so many hospital functions, she says.
"We are currently seeing a trend of nurses moving into the arena of the C-suite," Turley says. "You will see more of that in the future. Physicians and nurses are seeing that they have some of the skill sets that are required to make changes in healthcare organizations."
But they typically don't have all the requisite skills for the top jobs at healthcare organizations. Nurses often lack the business education and financial grounding usually required for executive leadership. They must take business and finance courses that will complement their clinical background, Turley says, which helps put nurse executives on par with their peers who earn healthcare administration degrees.
Graduating to the top job
More often, hospital CEOs are recruiting nurses to become COOs because of their knowledge about how various units within a hospital operate and integrate. Eventually, those nurse COOs graduate to the CEO level, Turley says. "It really helps to run an organization in a smooth fashion," she says.
According to a 2003 survey by the American Organization of Nurse Executives, or the AONE, and executive search firm Ballein Search Partners, 61% of senior nursing officers said they have responsibilities comparable to those of the traditional COO position.
By working with clinical departments as well as other hospital staffers who don't interact with patients, nurse executives get an appreciation for other departments and the issues that affect them, says Joyce Johnson, chief nursing officer and COO at 609-bed Georgetown University Hospital, Washington.
"Nursing links so many services," Johnson says. "We have had years of experience helping the institution work together. Nurses know the core business of patient care. That is a tremendous advantage because it is easier to understand what needs to be done."
When Anthony Disser decided to make a career move at post-acute provider Kindred Healthcare, the registered nurse believed that he could take his clinical experience straight to the executive level where he could mix his background in working with patients and the business of running a hospital.
He compared his graduation from working at the bedside to the corporate suite to that of a former baseball player who returns to the dugout as a manager.
"Those who have a clinical background know the product," says Disser, senior vice president of clinical operations at Kindred, which operates 67 long-term acute-care hospitals. "They know the joy and agony of it. They know what it is like to put a hand on a patient."
Disser, who has spent 23 years in the healthcare industry, says he balances the business decisions made on the executive level with the clinical side of nursing. While working as a nurse at St. Margaret's Hospital in Spring Valley, Ill., Disser earned a master's degree in nursing and hospital administration at Northern Illinois University.
"I am a clinical person and a business person," Disser says. "The best leaders can do that. They know how to switch-hit."
Nurse executives are highly skilled at designing programs and establishing business plans based on the needs of patients. They can also gauge how the public will respond to various hospital services because they see members of the community daily, says Pamela Thompson, CEO of the AONE. The association has grown steadily since its founding in 1967 and now represents about 4,300 nurse executives, up from 3,900 in 2000.
"They have a unique experience they bring to the role," Thompson says. "If you look at the role nursing plays, it lays the groundwork for everybody in the executive practice."
Getting down to business
The road that nurses take to become CEOs and COOs certainly isn't easy street. Nurses who move to top leadership positions must be in tune with the hospital's finances and make sure they keep the entire organization in mind when making administrative decisions, Turley says. The academic training required of nurse executives is only one part of the equation. As most executives soon find out-and Irsik can attest-on-the-job education also plays a crucial role.
Irsik, who took over as Prattville Baptist's administrator in March, says she is already putting her business administration courses to good use in the facility's day-to-day operations. "There is a lot of finance in this role and the education will help me do a better job," she says. "It will give me more financial background."
The University of Pennsylvania's Wharton School of Business offers an intensive three-week nurse executive program for chief nursing officers who are seeking more education to propel their move to the COO/CEO level. Most of the program is tailored for nurses seeking more training in hospital finances.
The program accepts 40 nurses annually from the U.S., Canada and abroad who take finance and accounting courses and engage in business simulation exercises. The nurses divide into teams and operate a fictitious hospital system where they make decisions and integrate concepts into the business model. They then see how their decisions affect the system.
Formal continuing education was completed by 39% of the senior nursing officers who were surveyed by the AONE and Ballein, with a little over half choosing the Wharton program. Approximately 40% of those responding said they gained their executive skills through their work experience.
Nurses in the Wharton program also learn how to consider the hospital organization as a whole and think outside of their nursing background. They learn how to tackle financial issues, such as Medicare reimbursement, an important skill for CEOs in recent years, says Gregory Shea, an adjunct professor who oversees the program.
"There seems to be a need for increased education about financial performance and strategy," Shea says. "Most institutions are so conscious about their financial performances."
But Turley says an emphasis on patient quality and safety is a specialty for executives with nursing backgrounds, and she says they need to keep patients in mind when making business decisions. "We must focus more on the clinical side," she says. "Then you complement it with advanced degrees in finance."
Nurse executives not only must have a foundation in healthcare finance and business practices, but they must reach out to staff members and motivate them to do their best work, executives say. Executives who have risen through the nursing ranks often have an advantage because they may know many of their managers and staff members from their days at the bedside.
Hospital workers, especially on the clinical side, will be expecting nurse executives to have empathy for the challenges they face, Johnson says.
Executives also have to be aware of how creating policy procedures can put more responsibility in one area of the hospital, Johnson says. "You have to make certain the decisions you are making are balanced in the best interests of the organization," she says. "You don't want one department doing all the work. You have to appreciate the impact of your initiative on all departments."
Disser, who attended the Wharton program in 2000, says balancing executive duties with managing the clinical staff isn't so difficult because he knows firsthand the challenges they face daily.
"I do have an understanding of the pain of a tough business decision and the right thing to do for a patient," Disser says. "I think I can talk with some passion about the work and I can relate. I can create a culture for them to do the work."
The physician perspective
Working with physicians also can present challenges for nurse executives who, in some cases, have had adversarial relationships with physicians in their previous roles.
At Prattville Baptist, Irsik is still building a relationship with physicians, which she considers important for all sides of the operation.
"They have accepted me in the clinical role; now I am going to work closely with them to develop a business relationship," she says. "That is going to take time."
The AONE's Thompson says nurse executives usually have a good working relationship with physicians because "There is a common understanding of clinical practices."
At Georgetown, Johnson says she doesn't see a conflict between nurse executives and physicians. Physicians respect the nursing profession and the clinical expertise nurses provide at the bedside, although sometimes the respect is unspoken. "They have been very supportive and helpful," she says.
Turley says the respect between nurse executives and physicians is the result of a new focus on patient outcomes and a move away from the executives' emphasis on only the financial aspects of hospital operations.
"We are evolving into providing healthcare in a whole new different way," she says. "We will see a tremendous focus on patient quality and safety."