What is a chief nursing officer? A chief nursing officer (CNO) is the registered nurse at the very top of the executive chain of command within a medical center or another healthcare system. He or she reports directly to the organization’s chief executive officer (CEO) and holds administrative and supervisory responsibility for every nursing service delivered across all medical units in that organization. In some organizations, CNOs assume the title of Vice President of Nursing while in others, they’re called the Chief Nursing Executive. Keep reading to find out everything there is to know about the role of the chief nursing officer – what is it, steps to become, pros & cons, and salary.
What does a chief nursing officer do? Like other high-ranking executives within a healthcare organization, chief nursing officers are charged with creating and implementing the policies that will help ensure the success of that organization. Though “chief nursing officer” is not a clinical position, CNOs must have prior hands-on patient care experience to be successful in this role because they are frequently called upon to evaluate the utility of various clinical interventions. The duties of a chief nursing officer include:
Whether a medical facility is a nonprofit or for-profit enterprise, it must optimize its revenue cycle while still achieving quality patient outcomes in order to remain operative. A good CNO advocates for nurses and promotes a workplace characterized by effective communication, interdisciplinary cooperation, and responsible deployment of resources.
Healthcare is one of the most heavily regulated industries, so one of a CNO’s most important responsibilities is ensuring that all nurses in an organization comply with legal mandates designed to safeguard privacy, protect patients’ rights and fight abuse and fraud. CNOs also promote nursing practices based upon evidence-based science.
CNOs are in charge of preparing the budget for all nursing departments and nursing services in the organization that employs them. Nursing salaries alone make up 40 percent of routine costs associated with every hospital, so the CNO’s impact on a facility’s overall budget can be huge.
Chief nursing officers approve quantifiable measures called metrics that are used to ensure quality patient care within nursing departments. They also take part in the process that evaluates how well each nursing department is meeting its benchmarks.
The chief nursing officer typically manages a facility’s director of nursing as well as the nurse managers who head up the units within that facility that provide various types of specialized patient care and services.
Nurse managers typically have primary responsibility for hiring and terminating staff nurses. But all hires and firings must be approved by the CNO.
Even before the COVID-19 pandemic, RN turnover in hospital settings was more than 17 percent, thereby greatly increasing the costs of hospital care. RN turnover has increased dramatically since 2020. One of the CNO’s most important tasks is designing nurse retention programs that work.
CNOs represent nurses at administrative meetings. They regularly report to hospital CEOs and executive board members about developments that involve the hospital’s nursing services and nursing staff.
Constructive partnerships between nurses and physicians are vital to ensuring positive patient outcomes in a hospital setting. CNOs set the tone by encouraging communications based on trust and mutual respect.
CNOs are charged with introducing measures aimed at healthcare quality improvements as well as coordinating the implementation of new nursing strategies.
Patient safety is mandated by government agencies as well as by hospital administrators, and CNOs must ensure that nursing procedures, staff rules and patient policies are designed to put patient safety first.
Chief nursing officers continually assess and help implement new medical technologies that have the potential to make nursing operations more efficient and to improve patient outcomes.
A chief nursing officer needs to maintain constant communication with the nursing staff he or she manages, so the nation’s nearly 37,500 CNOs typically work from onsite offices at their places of business. Eighty-four percent of CNOs work for organizations that provide direct patient care. Another 6 percent work for government agencies while 3 percent work for private industries like insurance companies or pharmaceutical firms. The largest CNO employers include:
In large healthcare systems, chief nursing officers head a nursing hierarchy comprised of multiple directors of nursing and nurse managers. The CNO is responsible for ensuring the excellence of nursing services across all hospitals, outpatient care clinics and other healthcare providers that comprise a medical system. Eighteen percent of CNOs in the U.S. work for large healthcare systems that employ more than 10,000 employees.
In medical centers and hospitals, the chief nursing officer’s responsibilities typically involve setting standards for patient care, signing off on the protocols and standards established for achieving those standards, and managing the nurse administrators who oversee the work of nurses throughout all the facility’s many departments. Forty-two percent of CNOs work in medical centers and hospitals with 1,000 to 10,000 employees.
In ambulatory care units, outsourced emergency departments, urgent care clinics, and other outpatient care settings, CNOs create quantifiable goals for nurses that facilitate the ways that patients receive the treatments prescribed by their medical teams.
In skilled nursing facilities, chief nursing officers are not only responsible for managing RNs but are also responsible for managing the medical assistants that do the majority of hands-on care.
Chief nursing officers are executives, which means they work from offices. However, they often work far more than the standard 40-hour, 9-to-5 work week because their work involves overseeing nursing departments. Depending on their employment setting, you will find CNOs checking in with staff occasionally on weekends, on evening shifts, and even on night shifts. Since chief nursing officers, for the most part, are salaried employees, the stipulations of the Fair Labor Standards Act (FLSA) do not apply to them. They do not receive overtime pay for hours worked over 40 per workweek.
A chief nursing officer’s actual job description may vary greatly according to the needs of the employer. However, apart from education and training, there are certain common personality characteristics that the majority of CNOs display. These personality traits include:
An efficient chief nursing officer is someone for whom arriving on time, making lists, and delegating tasks to qualified individuals is second nature.
Critical thinkers are careful observers who understand their own biases and take pains to keep these in check so that the conclusions they come to will be most meaningful. As a CNO, you must be able to stay objective as you evaluate situations and information. You must focus on facts and make an effort to keep your emotions from influencing your reactions.
Healthcare delivery is constantly evolving, and as a CNO, you must be able to keep up with all the changes. You must also be able to recognize when systems need to change to improve issues like patient safety, patient outcomes, and general organizational efficiency.
As a CNO, you must have a thorough understanding of your facility’s policies and best practices as they relate to nursing. You must have the resources to double-check your own work and the work that others do at your behest. You will probably be called upon to track many projects simultaneously, and you must organize a system for staying on top of them all.
When you’re a chief nursing officer, the buck stops with you. You will be accountable for everything that goes on in your facility’s nursing departments under your watch. Hundreds of nurses may be interacting with patients on any given day, but you must be comfortable assuming responsibility for all the care those nurses are delivering.
Communicating means the ability to listen as well as to speak. CNOs must be able to communicate effectively both in writing and in speech, and they must be equally proficient whether speaking publicly or talking one-on-one.
Chief nursing officers are good leaders, and the ability to make timely, evidence-based decisions is one of the hallmarks of a good leader.
Another term for vision is “the big picture.” As a CNO, you must be able to visualize a future in which your plans for the future of your organization have been realized. And you must be able to motivate the people you manage to work toward that future.
A chief nursing officer must be able to balance his or her role as a nurse and patient advocate with an understanding of the importance of the business side of healthcare. This calls for a highly specialized skill set. Here are the most important skills needed to be a chief nursing officer:
Juggling multiple concurrent projects within an allotted timeframe is no small feat. As a chief nursing officer, you will have to understand how to organize your time and divide it most effectively among competing priorities.
As a chief nursing officer, you must have a comprehensive overview of the organization that employs you and a thorough understanding of how that organization’s various components mesh to produce desired results. You must understand the significance of every one of that organization’s operations from staff management to patient care to financial reimbursement.
Patients in the facility you work for as a CNO may face a number of obstacles to the delivery of quality healthcare, and you must be able to identify those obstacles and tackle them efficiently. The nurses you lead may also face issues, which will become your responsibility to solve. At the same time, it will be important for you to recognize which decisions are outside the scope of your position so that you can seek guidance from your supervisors.
The chief nursing officer role is primarily a business role, which means that any prospective CNO has to have a healthy regard for the bottom line. As a CNO, you’ll need to have a genuine interest in the entire healthcare ecosystem and the ways in which healthcare industry trends ultimately impact clinical decision-making.
Chief nursing officers must have superior computational skills so that they’re able to analyze and report data in formats that nurses and healthcare executives alike can easily understand.
CNOs must be comfortable with all standard electronic medical record (EMR) software as well as the other technology and tools used to deliver quality patient care in a rapidly evolving hospital setting.
As a CNO, you’ll be charged with ensuring regulatory compliance, which means you’ll have to have an in-depth understanding of the legal requirements your nurses and other staff members face as well as extensive knowledge of nursing best practices.
While a chief nursing officer position may look good on paper, not everyone’s cut out for it. If you’re considering taking this job, here are some questions you should be asking yourself. If you answer, “No,” to more than three of these questions, chances are you’d be better off considering another kind of employment.
The CNO job comes with a high salary and plenty of perks, but it’s a lot of work, and that work entails a high degree of responsibility and accountability. You will be running around from the instant you first fly through the door in the morning till the moment you leave at night, and chances are you will find yourself staying late—as well as coming in on your days off.
Executive positions require a lot of meetings, and those meetings may frequently seem unproductive. As a chief nursing officer, though, you won’t be able to show your frustrations. Instead, you must stay the course and look for ways to effectively promote your agenda.
Coordinating all of a medical center’s daily operations is a high-stakes job beset with crises. As soon as you put out one fire, another one may break out. If you don’t have the equanimity to deal with this kind of heat, it’s best to stay out of the kitchen.
As a CNO, you will be expected to spend time in both settings and to navigate between them comfortably. If you’re not as confident discussing the impact enhanced EMRs will have on reimbursements as you are talking about how the latest generation of antibiotics can improve patient outcomes then it might be wise to focus on a different employment opportunity.
The Chief Nursing Officer role is not a clinical position although it does require clinical experience. Still, if you’re a nurse whose primary job satisfaction is closely aligned with delivering hands-on care and forging special relationships with the patients you care for, it’s likely you won’t find the same satisfaction with the CNO job description.
CNOs are leaders, and leaders invite detractors as well as admirers. Are you comfortable being in a position where some of your decisions may cause some of your coworkers to criticize you, possibly unfairly? This is a position that public figures often find themselves in, and as a chief nursing officer, you will be the public face of nursing at the facility that employs you.
As noted above, the chief nursing officer job is primarily a business position. True, you will be the public face of the nurses who work at your facility and have plenty of opportunities to act as a nursing advocate. But there are likely to be occasions where you may be called upon to make decisions that are not necessarily in nurse employees’ best interests but are in the best business interests of your organization. Will you be able to deal with that?
As a chief nursing officer, you will be making a lot of decisions, and the process you use to arrive at those decisions must be an objective one. A good demonstration of this can be found in personnel decisions. If a hiring process comes down to two candidates, you can’t pick one just because you find yourself liking him or her more than the other. There must be a compelling evidence-based reason for your choice.
Micromanaging is one of the signs of an incompetent leader. Good leaders know how to delegate and how to devise performance metrics that measure how well team members perform the tasks the leader has assigned. CNOs can’t possibly perform every one of the tasks that fall under their purview personally, so they must be able to delegate effectively.
To become a CNO, at the very least you will need a Bachelor of Science in Nursing (BSN). Even better, though, would be a Master of Science in Nursing (MSN) with a concentration in healthcare administration or nursing leadership. A nurse who is interested in this line of work is likely to pursue one of several certifications in the field; these certifications include Nurse Executive, Certification (NE-BC), Executive Nursing Practice Certification (CENP), Nurse Manager and Leader Certification (CNML), Clinical Nurse Leader (CNL), and Nurse Executive, Advanced Certification (NEA-BC). Additionally, they will want to have some solid experience as a nurse manager, supervisor, director, or assistant director on their resume.
Though 26 percent of chief nursing officers hold associate degrees from community colleges or hospital diploma programs, these CNOs tend to be individuals on the older side of the nurse leadership spectrum who are looking at retirement in the next few years. Some 71 percent of CNOs hold BSNs, and 24 percent of CNOs have advanced their education to the MSN level. It’s safe to say that if you want to become a chief nursing officer today, you will have to earn a BSN at the very least. That means you’ll have to graduate from high school with a diploma. Competition for places in college and university nursing programs is intense, so your high school transcript should include chemistry, biology, and math classes.
There are nearly 1,000 baccalaureate nursing programs in the U.S. There are also an increasing number of programs designed for RNs who’ve graduated from community colleges or hospital diploma programs and who want to work toward a BSN. Nursing baccalaureate curricula typically include coursework that focuses on leadership theory, healthcare policy and inter-professional communication, which are all things an effective nurse leader must understand.
There are more than 500 colleges and universities offering graduate nursing programs. Many of these programs offer distance learning options. Programs that are often singled out for the excellence of their nurse leadership programs include:
Becoming a chief nursing officer entails becoming licensed in the state in which you hope to work. That means passing the National Council Licensure Examination for Registered Nurses (NCLEX-RN) exam. The fee for the NCLEX-RN is $200. The exam utilizes computer adaptive testing technologies, so the questions you’ll be answering are dynamically generated by an algorithm, which bases its choices on the difficulty of those questions. The passing score for the NCLEX-RN is zero logits.
Once you’ve passed the NCLEX-RN exam, you must apply for licensure with the Board of Nursing in the state where you wish to work. Licensing regulations vary from state to state.
While no specific certifications are required to become a chief nursing officer, a number of certifications exist in the areas of healthcare administration, nurse leadership and nurse management that may greatly enhance your ability to land the job you want. These certifications include:
The American Nurses Credentialing Center (ANCC) offers the NE-BC certification. It’s intended for nurses who want to become the type of nurse leaders that make day-to-day decisions at the hospital unit or departmental level. The certification exam is only open to RNs who hold a BSN degree or an MSN degree and who have been employed as a nurse manager, supervisor, director, or assistant director within the past five years. BSN degree holders are also required to complete 30 hours of continuing education credits in nursing administration within the past three years. The certifying exam consists of 150 scored multiple-choice questions; the maximum score is 500, and the passing score is 350. The test fee is $295 for ANA members and $395 for non-members.
The CENP certification is offered by the American Organization for Nursing Leadership (AONL). Exam eligibility is restricted to BSN degree holders with four years of experience in an executive nursing role and MSN degree holders with two years of experience in an executive nursing role. AONL members will pay $325 to take the exam while non-members will pay $450. The exam consists of 150 scored multiple-choice questions, and you must answer at least 108 of them to pass.
AONL also offers the CNML certification, which demonstrates your expertise in nurse management and is designed exclusively for nurse leaders in the nurse manager role. You don’t have to have a BSN to earn this credential: Nurse managers with associate degrees or hospital diplomas are eligible if they’ve accumulated 5,200 hours of experience as a nurse manager, while nurse managers with BSN degrees are eligible if they’ve accumulated 2,080 hours of experience as a nurse manager. The test consists of 115 questions that focus on financial management, human resource management, performance improvement, and strategic management and technology, and a minimum score of 70 is required to pass.
The CNL certification is offered by the American Association of Colleges of Nursing. It’s only open to graduates of accredited MSN programs or students in their last year of an accredited MSN program. The test fee is $425. The exam is comprised of 140 scored questions. To pass the exam, a candidate must score 350 or higher, but results are only reported to candidates as pass or fail.
ANCC also offers an advanced certification, NEA-BC, which is designed for high-level nurse managers who focus on high-level finance, resource management and system integration. You must have a master’s degree or higher to sit for this exam, and you must have held an administrative position at the nurse executive level for at least 24 months in the last five years. The exam consists of 125 scored multiple-choice questions, and to pass, you must answer at least 59 percent of the questions correctly. The exam fee for members of the American Nurses Association is $295; for non-members, it’s $395.
Prospective employers look most favorably upon candidates for chief nursing officer positions whose resumes contain solid administrative experience. Get your feet wet in a charge nurse position. From there, apply for nurse manager jobs that will give you experience in the everyday supervision of nursing staff. Following those experiences, apply for nurse director jobs that teach you how to assume oversight for hospital units at the departmental level.
There are no continuing education requirements specific to employment as a chief nursing officer, but all states have CEU requirements for RN licensure renewal. These requirements vary from state to state.
There’s no “one-size-fits-all” template for becoming a chief nursing officer. If you want to become a chief nursing officer, here’s what you’ll have to do:
While you’re still in high school, focus on the science curriculum. Take classes in chemistry, biology, math, and if the subjects are offered, anatomy and physiology.
Attain a BSN at an accredited nursing program affiliated with a college or a university. Yes, there are CNOs with Associate Degrees in Nursing (ADN), but most prospective employers prefer to hire nurse managers and administrators with a baccalaureate education.
In every state and the District of Columbia, passing the NCLEX-RN exam is a condition of nursing licensure.
Keep in mind that nursing license requirements differ from state to state.
Though CNO is not a clinical job, you will need some amount of clinical experience before you’ll be hired into that position. That means putting in at least two years as a staff nurse. In addition to bedside experience, you should seize any leadership opportunities that come your way such as charge nurse rotations and teaching in-services. You should also work at achieving any certifications that you are eligible to pursue.
At present, fewer than 25 percent of all CNOs hold MSN degrees, but you can expect that percentage to increase dramatically in the next few years. MSN nursing programs focus on specific areas of expertise, and MSN programs with a nursing administration focus best prepare RNs to assume leadership roles. Three percent of aspiring CNOs take their education one step further by pursuing a Doctor of Nursing Practice (DNP) degree with an emphasis in executive administration.
CNO is a nursing career option rather than a nursing career specialty, so there’s no set timeline associated with becoming a chief nursing officer. It will take you however long it takes you. At a minimum, it may take eight years. Realistically speaking, though, it’s likely to take twice that amount of time because prospective employers only want to hire the most seasoned leaders for this role.
One thing to keep in mind is that medical systems tend to favor internal candidates over external candidates for CNO promotions. You’ll want to identify every opportunity that signals to your employer you’re ready for more administrative responsibility. Larger medical centers and hospitals may even offer their own nurse leadership training programs that will groom you to work your way up the internal nurse leadership ladder.
Since CNO is a nursing career option rather than a nursing career specialty, no one set of costs can be associated with achieving this goal. Acquiring the education, nursing license and certifications that will make you a more competitive candidate for the job is likely to cost anywhere between $40,000 and $200,000. Keep in mind, though, that 26 percent of all chief nursing officers are graduates of associate degree and hospital diploma programs, and the total costs associated with these programs are unlikely to be more than $7,000 to $21,000.
Here’s what most nurses can expect to spend on CNO advancement:
You’ll spend $40,000 to $100,000 getting your nursing baccalaureate depending upon the school you attend. Public colleges and universities typically cost less than private colleges and universities, and you can expect to pay higher tuition if you attend a nursing program outside the state where you live.
Expect to pay $500 for a test prep course and $200 for the test itself.
Registered nurse licensing fees typically run between $125 and $200.
Expect to pay $500 for a test prep course and between $295 and $495 for each certification.
MSN programs vary in cost from $35,000 to $100,00.
You’ll spend anywhere between $41,120 and $202,000 on the training that will qualify you to apply for a chief nursing officer job.
The chief nursing officer is the most senior management position in a medical facility whose prerequisites include a nursing license. It’s the top of the line so far as nursing administration goes. By definition, then, there aren’t any career advancement opportunities for chief nursing officers per se.
However, chief nursing officers may go on to other executive positions inside the hospital hierarchy once they’ve ended their CNO tenure. A few CNOs have even gone on to become chief executive officers (CEOs) of the facilities that employ them. CEOs are the highest-ranking corporate executives within any organization; in a medical facility, the CEO is responsible for operations including planning, staffing, budgeting, and creating and implementing policies that affect the entire facility.
Chief nursing officers may also go on to become consultants. As consultants, former CNOs may work with healthcare providers, government agencies, and insurance companies.
Most registered nurses see the upper echelons of nurse management as undesirable. Only 11 percent of RNs are interested in becoming nurse managers of any kind. Here are 10 of the top cons of being a chief nursing officer.
While it’s true that 26 percent of working chief nurse officers are graduates of associate nursing or hospital diploma programs, those nurses have either subsequently gone on to earn BSNs and MSNs, or are nearing retirement age. If you’re a young RN with an eye on a CNO position, you’ll most likely need a BSN and an MSN. You might also want to minor in business administration as an undergraduate.
More than 70 percent of all nurses subsidized their nursing education through student loans. Nursing loan debt varies with the reputation of the nursing programs you attend: Students in nurse leadership programs at top-ranked Duke University end up with an average debt of $74,781; these students will likely be paying $300 a month over 10 years to whittle away this debt. The average graduate nursing school debt for all RNs from chief nursing officer down is between $40,000 and $50,000. Federal and state programs exist that offer nurse loan forgiveness.
One of the biggest disadvantages of being a chief nursing officer is that the salary you receive may look best on paper. The states that pay chief nursing officers the highest salaries frequently have high costs of living. Take California, for example: In the Golden State, chief nursing officers average $186,670 annually, but the cost of living in the Golden State is 50 percent more than the national average. From a financial point of view, you might be better off working in a state like New Mexico where the average CNO salary is close to the national average, but the cost of living is significantly below the national cost of living.
Why do most nurses enter the nursing profession? Because they relish the opportunity to provide the types of hands-on services that make a real difference in people’s lives. In fact, more than twice as many nurses who are seeking to advance their professional careers look forward to doing so through broadening their clinical skills. As a chief nursing officer, though, you won’t be providing hands-on services.
Another one of the cons of being a chief nursing officer is that CNOs typically work far more than 40 hours a week, which may make it difficult to maintain a satisfying personal life. Though CNOs are office personnel, they often work way beyond 5 p.m. It’s not unusual for a CNO to check in with employees working evening and night shifts, or on weekends and holidays. During crunch time—for example, when the nursing department’s budget is due CNOs may put in 12- or 16-hour days.
Paperwork is a requirement for executive positions like that of a chief nursing officer. As a chief nursing officer, you’ll be up to your elbows in forms, memos, white papers, studies, executive summaries, reports, and other documents. If you’re someone who finds paperwork tedious, CNO may not be the job for you.
As a staff nurse, you are entrusted with a great deal of responsibility, but that responsibility extends no farther than care and triage for a handful of patients. As a CNO, you’ll be assuming responsibility for the care and triage of every patient in your medical facility as well as managing nursing budgets, planning new patient services, representing nurses at board meetings, ensuring compliance with governmental regulations and advising other senior management partners on best nursing practices. The amount of responsibility you’ll be shouldering may seem overwhelming at times.
This is one of the biggest disadvantages of being a chief nursing officer, though it does not get talked about often. Floor nurses are very physically active; the average nurse typically walks between four and five miles, burning 1,400 calories in a 12-hour shift. In contrast, the chief nursing officer is a desk job. To stay physically fit, you may have to undertake an exercise regimen during your hours off.
When you become a member of the senior management team, many of your relationships with long-time colleagues will likely change. Friendships get tricky when power dynamics shift. As a chief nurse officer, you can’t play favorites. You have to evaluate all members of your team fairly, and this may have a negative impact on some of the relationships you’ve developed over the years.
Chief nurse officers often find themselves in the position of making decisions that are unpopular with the rank-and-file nursing staff. This is another one of the top cons of being a chief nursing officer. For example, you may be privy to financial information that forces you to lay off employees, but the sensitive nature of that information is such that you can’t share it, so your employee layoffs seem unjust and arbitrary. CNOs must develop a thick skin.
For a nurse with strong leadership qualities, there are many positive aspects to being a CNO. The advantages of being a chief nursing officer include money, independence and the opportunity to empower the nurses on your team to give the best patient care possible as you define it. Here are the top 10 pros of being a chief nursing officer.
Chief nursing officers have a great deal of control over how their jobs are structured. The facility’s CEO and board of directors may give them goals but how these goals should be achieved is often left entirely to the CNO. This gives chief nursing officers plenty of opportunities to implement their own independent vision of nurse excellence.
Chief nursing salaries are high, and that’s one of the top pros of being a chief nursing officer. The average starting salary for this position is just under $104,000 a year while CNOs with a decade’s worth of experience earn nearly $160,000 a year, which is more than 54 percent higher than the entry-level CNO salary. The average salary for a CNO is $147,182 a year; this figure is 89 percent higher than the average salary for all nurses ($77,976).
Your CNO skill set will make you a valuable staff addition to a wide variety of healthcare facilities. Depending upon your inclination, your skills are transferable between sprawling statewide medical systems, consolidated urban medical centers, or solo rural hospitals. You can even work for large physician practices if their nursing pool is large enough to warrant employing a chief nursing officer.
When you’re a chief nursing officer, you’ll never have to punch a clock. You can come to work when you want to and leave when you want to so long as you accomplish everything your CEO expects you to accomplish. You’ll probably end up putting in far more than 40 hours a week, but you’ll do so on your own terms.
The average age of chief nursing officers in the U.S. is 47, which means many of them will be looking at retirement within the next 10 to 15 years. These jobs will need to be filled as will newly created CNO jobs. Though the Bureau of Labor Statistics doesn’t track the demand for chief nursing officers specifically, the BLS does note that the overall demand for health service managers generally is expected to grow by a healthy 32 percent between 2020 and 2030. This is one of the biggest advantages of being a chief nursing officer.
One of the most rewarding aspects of becoming a CNO is that to a large degree, your employer’s success hinges upon your effectiveness. Nurses are the heart of every successful healthcare delivery system, and you are the person primarily responsible for overseeing nursing staff and nursing resources in that healthcare delivery system. It’s an opportunity to put your own stamp of excellence on patient care in a big way. For many CNOs, this is one of the top pros of being a chief nursing officer.
The CNO is responsible for coordinating all nursing operations in a medical facility. But in today’s increasingly complex healthcare delivery matrix, chief nursing officers must also understand business administration and finance. While CNOs may learn the fundamentals in MSN health management programs, they’ll likely hone their expertise in managing nursing budgets, establishing compensation wages, and planning new patient services on the job.
As a chief nursing officer, you’ll have the chance to meet other healthcare professionals who can be a source of new perspectives and fresh ideas that will aid you in your professional role.
Nurses love the nursing profession on the whole, but at any given time, between 15 and 20 percent of all nurses are ready to pursue a new career path. A position as a chief nursing officer will position you to make a vertical or lateral jump onto a new career trajectory that still allows you to leverage your education and experience in nursing. CNOs have gone on to become CEOs, consultants, media healthcare experts, medical-legal consultants, and healthcare entrepreneurs.
The starting salary of a chief nursing officer is $49.57 an hour, $8,590 a month, or $103,100 annually. (That hourly figure is more a useful metric than an actual unit of payment: Chief nursing officers are always salaried employees.) Executive employees in hospital settings like chief nursing officers are most often compensated using step rates; this ensures that executives are paid equitably according to their job duties and seniority.
| Hourly | $49.57 |
| Monthly | $8,590 |
| Annual | $103,100 |
The average chief nursing officer salary is $70.76 an hour, $12,270 a month, or $147,182 a year. CNOs usually achieve this milestone in their fifth continuous year of employment. The Chief nursing officer's salary depends upon several variables, the two most important of which are the cost of living in the location where the CNO is employed and the volume of patients the healthcare facility that employs them deals with regularly.
| Hourly | $70.76 |
| Monthly | $12,270 |
| Annual | $147,182 |
| (Source: Ziprecruiter.com) | |
The more seniority a chief officer has, the higher the chief nursing officer salary. CNOs with one to four years of experience on average earn $121,880 a year, which is 18 percent higher than the average CNO entry-level salary. Chief nursing officers with five to nine years of experience on average earn $143,560 a year, which is 39 percent higher than the average CNO entry-level salary. With two decades or more of experience, a chief nursing officer is likely to earn $195,060 annually, which is 89 percent more than the average entry-level CNO. Note, however, that chief nursing officer is a position where starting salaries can be quite high if you’ve been a high-performing CNO at a previous healthcare facility.
| Level of Experience | Hourly | Monthly | Annual |
| Entry-Level | $49.57 | $8,590 | $103,100 |
| 1-4 Years of Experience | $58.60 | $10,160 | $121,880 |
| 5-9 Years of Experience | $69.02 | $11,960 | $143,560 |
| 10-19 Years of Experience | $76.88 | $13,330 | $159,920 |
| 20 Years or More Experience | $93.78 | $16,260 | $195,060 |
Along with their base salaries, chief nursing officers are eligible for a wide range of perks called benefits. High-performing chief nursing officers are in a position to negotiate the benefits that will persuade them to accept a particular job. Chief nursing officer benefits frequently involve an annual bonus with a guaranteed minimum in addition to base pay. Other benefits include medical insurance, life insurance, mortgage assistance and vested contributions to a supplemental executive retirement plan. Note that nonprofit hospitals frequently offer chief nursing officers larger salaries and more lucrative perks than for-profit hospitals do.
Average chief nursing officer salaries range from a low of $125,850 in Alabama to a high of $186,670 in California. CNOs in the Golden State earn salaries that are 48 percent higher than CNOs in the Yellowhammer State.
CNO salaries are highest in northeastern states like New Jersey (($169,100), New York ($167,000) and Massachusetts (($163,730) and western states like California, Washington (($160,060), and Oregon ($160,840). The lowest paying states for chief nursing officers tend to be southeastern states like Alabama, Florida ($120,250), and South Carolina ($120,400).
This salary differential is largely due to regional differences in the cost of living. The cost of living in California is 68 percent higher than the cost of living in Alabama, so it could be argued that CNOs in the Yellowhammer State are making out better since they have more purchasing power.
| State | Hourly | Monthly | Annual |
| Alabama | $60.50 | $10,490 | $125,850 |
| Alaska | $66.06 | $11,450 | $137,400 |
| Arizona | $68.90 | $11,940 | $143,320 |
| Arkansas | $60.79 | $10,540 | $126,440 |
| California | $89.75 | $15,560 | $186,670 |
| Colorado | $66.08 | $11,450 | $137,450 |
| Connecticut | $74.63 | $12,940 | $155,220 |
| Delaware | $68.43 | $11,860 | $142,330 |
| Florida | $62.61 | $10,850 | $130,220 |
| Georgia | $65.51 | $11,360 | $136,270 |
| Hawaii | $72.82 | $12,620 | $151,470 |
| Idaho | $66.81 | $11,580 | $138,970 |
| Illinois | $69.41 | $12,030 | $144,380 |
| Indiana | $69.09 | $11,980 | $143,700 |
| Iowa | $72.75 | $12,610 | $151,310 |
| Kansas | $63.38 | $10,990 | $131,820 |
| Kentucky | $62.02 | $10,750 | $129,010 |
| Louisiana | $67.09 | $11,630 | $139,540 |
| Maine | $67.14 | $11,640 | $139,650 |
| Maryland | $67.90 | $11,770 | $141,240 |
| Massachusetts | $78.72 | $13,640 | $163,730 |
| Michigan | $64.57 | $11,190 | $134,310 |
| Minnesota | $72.74 | $12,610 | $151,290 |
| Mississippi | $66.55 | $11,540 | $138,420 |
| Missouri | $64.24 | $11,130 | $133,610 |
| Montana | $68.08 | $11,800 | $141,610 |
| Nebraska | $67.52 | $11,700 | $140,440 |
| Nevada | $77.32 | $13,400 | $160,820 |
| New Hampshire | $71.38 | $12,370 | $148,480 |
| New Jersey | $81.30 | $14,090 | $169,100 |
| New Mexico | $73.53 | $12,750 | $152,940 |
| New York | $80.29 | $13,920 | $167,000 |
| North Carolina | $64.96 | $11,260 | $135,110 |
| North Dakota | $64.66 | $11,210 | $134,500 |
| Ohio | $66.65 | $11,550 | $138,640 |
| Oklahoma | $69.09 | $11,980 | $143,710 |
| Oregon | $77.33 | $13,400 | $160,840 |
| Pennsylvania | $68.42 | $11,860 | $142,310 |
| Rhode Island | $71.08 | $12,320 | $147,850 |
| South Carolina | $61.94 | $10,740 | $128,830 |
| South Dakota | $65.62 | $11,370 | $136,480 |
| Tennessee | $56.38 | $9,770 | $117,260 |
| Texas | $70.75 | $12,260 | $147,160 |
| Utah | $65.62 | $11,370 | $136,480 |
| Vermont | $66.18 | $11,470 | $137,660 |
| Virginia | $66.39 | $11,510 | $138,090 |
| Washington | $76.95 | $13,340 | $160,060 |
| West Virginia | $60.61 | $10,510 | $126,060 |
| Wisconsin | $68.79 | $11,920 | $143,090 |
| Wyoming | $65.40 | $11,340 | $136,030 |
Just as variation in CNO salary exists from state to state, so can variation exist from city to city in the same state. In Texas, for example, where the average CNO compensation is $147,160 a year, regional salaries vary from a high of $159,100 in Houston (8 percent more than the average state salary) to a low of $143,700 in San Antonio (2 percent less than the average state salary). In part, this reflects cost of living differentials: The cost of living in Houston is 7 percent higher than the cost of living in San Antonio. But in part, it reflects market competition for chief nursing officer services.
Houston is home to the largest medical center in the world. The Bayou City is a healthcare hub with more than 85 hospitals and more than 19,000 patient beds; its healthcare sector employs more than 10,000 people, almost 7 percent of the city’s workforce. Competition for high-performing healthcare executives like CNOs is fierce in Houston. In contrast, San Antonio has far fewer hospitals, and healthcare doesn’t play as large a role in the city’s economy. Hence, competition for talented CNOs is less intense, and salaries are commensurately lower.
| Metro | Hourly | Monthly | Annual |
| Akron, OH | $66.06 | $11,450 | $137,400 |
| Albany-Schenectady-Troy, NY | $72.80 | $12,620 | $151,420 |
| Albuquerque, NM | $72.73 | $12,610 | $151,280 |
| Allentown-Bethlehem-Easton, PA-NJ | $67.01 | $11,620 | $139,390 |
| Ann Arbor, MI | $68.59 | $11,890 | $142,670 |
| Asheville, NC | $64.48 | $11,180 | $134,110 |
| Atlanta-Sandy Springs-Roswell, GA | $65.69 | $11,390 | $136,640 |
| Austin-Round Rock, TX | $70.31 | $12,190 | $146,240 |
| Baltimore-Columbia-Towson, MD | $68.01 | $11,790 | $141,460 |
| Baton Rouge, LA | $66.31 | $11,490 | $137,930 |
| Birmingham-Hoover, AL | $62.55 | $10,840 | $130,110 |
| Boise City, ID | $67.99 | $11,780 | $141,410 |
| Boston-Cambridge-Nashua, MA-NH | $80.09 | $13,880 | $166,590 |
| Bridgeport-Stamford-Norwalk, CT | $74.74 | $12,960 | $155,460 |
| Buffalo-Cheektowaga-Niagara Falls, NY | $70.86 | $12,280 | $147,380 |
| Cape Coral-Fort Myers, FL | $72.64 | $12,590 | $151,100 |
| Champaign-Urbana, IL | $69.06 | $11,970 | $143,640 |
| Charleston-North Charleston, SC | $62.39 | $10,810 | $129,770 |
| Charlotte-Concord-Gastonia, NC-SC | $63.29 | $10,970 | $131,640 |
| Chattanooga, TN-GA | $57.61 | $9,990 | $119,830 |
| Chicago-Naperville-Elgin, IL-IN-WI | $71.52 | $12,400 | $148,760 |
| Cincinnati, OH-KY-IN | $67.84 | $11,760 | $141,100 |
| Cleveland-Elyria, OH | $71.11 | $12,330 | $147,910 |
| Colorado Springs, CO | $64.81 | $11,230 | $134,800 |
| Columbia, SC | $60.28 | $10,450 | $125,390 |
| Columbus, OH | $66.00 | $11,440 | $137,290 |
| Dallas-Fort Worth-Arlington, TX | $70.98 | $12,300 | $147,630 |
| Dayton, OH | $65.96 | $11,430 | $137,200 |
| Deltona-Daytona Beach-Ormond Beach, FL | $63.14 | $10,940 | $131,330 |
| Denver-Aurora-Lakewood, CO | $67.36 | $11,680 | $140,110 |
| Des Moines-West Des Moines, IA | $74.16 | $12,850 | $154,250 |
| Detroit-Warren-Dearborn, MI | $64.68 | $11,210 | $134,530 |
| Durham-Chapel Hill, NC | $69.11 | $11,980 | $143,740 |
| El Paso, TX | $67.88 | $11,770 | $141,200 |
| Fort Wayne, IN | $68.25 | $11,830 | $141,960 |
| Grand Rapids-Wyoming, MI | $63.06 | $10,930 | $131,170 |
| Greenville-Anderson-Mauldin, SC | $61.49 | $10,660 | $127,890 |
| Gulfport-Biloxi-Pascagoula, MS | $64.50 | $11,180 | $134,150 |
| Hartford-West Hartford-East Hartford, CT | $75.68 | $13,120 | $157,420 |
| Houston-The Woodlands-Sugar Land, TX | $76.49 | $13,260 | $159,100 |
| Huntington-Ashland, WV-KY-OH | $61.86 | $10,720 | $128,670 |
| Huntsville, AL | $59.75 | $10,360 | $124,270 |
| Indianapolis-Carmel-Anderson, IN | $71.51 | $12,400 | $148,750 |
| Jackson, MS | $70.19 | $12,170 | $145,990 |
| Jacksonville, FL | $65.69 | $11,390 | $136,630 |
| Johnson City, TN | $50.64 | $8,780 | $105,330 |
| Kansas City, MO-KS | $66.91 | $11,600 | $139,170 |
| Kingsport-Bristol-Bristol, TN-VA | $54.08 | $9,370 | $112,480 |
| Knoxville, TN | $53.24 | $9,230 | $110,740 |
| Las Vegas-Henderson-Paradise, NV | $77.04 | $13,350 | $160,240 |
| Lexington-Fayette, KY | $60.50 | $10,490 | $125,850 |
| Little Rock-North Little Rock-Conway, AR | $61.01 | $10,580 | $126,900 |
| Los Angeles-Long Beach-Anaheim, CA | $84.63 | $14,670 | $176,020 |
| Louisville/Jefferson County, KY-IN | $66.64 | $11,550 | $138,610 |
| Madison, WI | $70.50 | $12,220 | $146,630 |
| McAllen-Edinburg-Mission, TX | $70.56 | $12,230 | $146,770 |
| Memphis, TN-MS-AR | $58.28 | $10,100 | $121,220 |
| Miami-Fort Lauderdale-West Palm Beach, FL | $57.82 | $10,020 | $120,260 |
| Milwaukee-Waukesha-West Allis, WI | $66.58 | $11,540 | $138,490 |
| Minneapolis-St. Paul-Bloomington, MN-WI | $72.86 | $12,630 | $151,550 |
| Nashville-Davidson--Murfreesboro--Franklin, TN | $58.78 | $10,190 | $122,270 |
| New Haven, CT | $72.93 | $12,640 | $151,690 |
| New Orleans-Metairie, LA | $66.87 | $11,590 | $139,080 |
| New York-Newark-Jersey City, NY-NJ-PA | $96.66 | $16,760 | $201,060 |
| North Port-Sarasota-Bradenton, FL | $66.41 | $11,510 | $138,140 |
| Oklahoma City, OK | $69.18 | $11,990 | $143,900 |
| Omaha-Council Bluffs, NE-IA | $69.61 | $12,070 | $144,790 |
| Orlando-Kissimmee-Sanford, FL | $64.09 | $11,110 | $133,310 |
| Palm Bay-Melbourne-Titusville, FL | $68.00 | $11,790 | $141,440 |
| Pensacola-Ferry Pass-Brent, FL | $65.58 | $11,370 | $136,400 |
| Philadelphia-Camden-Wilmington, PA-NJ-DE-MD | $70.91 | $12,290 | $147,490 |
| Phoenix-Mesa-Scottsdale, AZ | $68.64 | $11,900 | $142,770 |
| Pittsburgh, PA | $70.32 | $12,190 | $146,270 |
| Portland-Vancouver-Hillsboro, OR-WA | $79.84 | $13,840 | $166,060 |
| Providence-Warwick, RI-MA | $71.12 | $12,330 | $147,930 |
| Raleigh, NC | $66.86 | $11,590 | $139,060 |
| Richmond, VA | $65.26 | $11,310 | $135,740 |
| Riverside-San Bernardino-Ontario, CA | $82.80 | $14,350 | $172,230 |
| Rochester, MN | $72.04 | $12,490 | $149,850 |
| Rochester, NY | $73.04 | $12,660 | $151,920 |
| Sacramento--Roseville--Arden-Arcade, CA | $89.56 | $15,520 | $186,290 |
| Salt Lake City, UT | $67.95 | $11,780 | $141,330 |
| San Antonio-New Braunfels, TX | $69.09 | $11,980 | $143,700 |
| San Diego-Carlsbad, CA | $85.11 | $14,750 | $177,020 |
| San Francisco-Oakland-Hayward, CA | $107.87 | $18,700 | $224,370 |
| San Jose-Sunnyvale-Santa Clara, CA | $113.30 | $19,640 | $235,660 |
| Seattle-Tacoma-Bellevue, WA | $79.40 | $13,760 | $165,150 |
| Springfield, MA-CT | $72.42 | $12,550 | $150,640 |
| Springfield, MO | $60.09 | $10,420 | $124,980 |
| St. Louis, MO-IL | $63.34 | $10,980 | $131,740 |
| Syracuse, NY | $67.02 | $11,620 | $139,410 |
| Tampa-St. Petersburg-Clearwater, FL | $61.09 | $10,590 | $127,070 |
| Toledo, OH | $65.11 | $11,290 | $135,420 |
| Tucson, AZ | $67.87 | $11,760 | $141,160 |
| Tulsa, OK | $68.91 | $11,940 | $143,330 |
| Virginia Beach-Norfolk-Newport News, VA-NC | $64.18 | $11,130 | $133,500 |
| Washington-Arlington-Alexandria, DC-VA-MD-WV | $71.45 | $12,390 | $148,620 |
| Wichita, KS | $59.25 | $10,270 | $123,250 |
| Winston-Salem, NC | $69.62 | $12,070 | $144,810 |
| Worcester, MA-CT | $78.64 | $13,630 | $163,580 |
As noted above, the highest paying states for chief nursing officers tend to be in the northeast or the far west. The highest-paid chief nursing officers work in California. CNOs in the Golden State average $186,670 annually, which is 10 percent higher than CNOs earn in New Jersey, the next highest-paying state, where they earn $169,100 a year. This is related both to California’s high cost of living and to the important role that healthcare plays in the state’s economy. Healthcare inflation is a particular problem in California, so talented chief nursing officers are prized because they work to help keep the costs of hospital healthcare manageable.
| Rank | State | Average Annual Salary |
| 1 | California | $186,670 |
| 2 | New Jersey | $169,100 |
| 3 | New York | $167,000 |
| 4 | Massachusetts | $163,730 |
| 5 | Oregon | $160,840 |
| 6 | Nevada | $160,820 |
| 7 | Washington | $160,060 |
| 8 | Connecticut | $155,220 |
| 9 | New Mexico | $152,940 |
| 10 | Hawaii | $151,470 |
Unsurprisingly, all but one of the highest paying metros for chief nursing officers are in California. The highest-paid chief nursing officers are employed in the San Jose-Sunnyvale-Santa Clara where they earn $235,660 a year, which is 60 percent more than the state average. Even in sparsely populated areas of California like Yuba City in Sutter County, chief nursing officers earn $190,870 annually—which is 2 percent more than the state average but still 30 percent higher than the national average. A 2005 study published in the professional journal Health Affairs found that in California, administrative expenditures—including hospital executive salaries—were equivalent to more than 20 percent of all hospital revenues.
| Rank | Metro | Average Annual Salary |
| 1 | San Jose-Sunnyvale-Santa Clara, CA | $235,660 |
| 2 | San Francisco-Oakland-Hayward, CA | $224,370 |
| 3 | Napa, CA | $223,330 |
| 4 | Vallejo-Fairfield, CA | $213,650 |
| 5 | New York-Newark-Jersey City, NY-NJ-PA | $201,060 |
| 6 | Yuba City, CA | $190,870 |
| 7 | Sacramento--Roseville--Arden-Arcade, CA | $186,290 |
| 8 | San Luis Obispo-Paso Robles-Arroyo Grande, CA | $185,910 |
| 9 | Salinas, CA | $185,240 |
| 10 | El Centro, CA | $179,870 |
Large medical systems with 10,000 employees or more pay the highest salaries to chief nursing officers and other healthcare executives. In part, this is an acknowledgment of the fact that coordinating nursing operations for a large medical system that easily employs 3,000 or more nurses is a far more complex job than coordinating operations for a smaller nursing staff. But it also reflects the fact that large healthcare organizations can afford to pay employees more since these organizations can take advantage of economies of scale that allow them to keep operational costs down.
Here are five tips that may enable you to maximize your earning potential as a chief nursing officer:
RNs who’ve earned a DNP degree generally earn higher salaries than RNs with MSN degrees. Although specific data comparing the salaries of DNP-educated CNOs to MSN-educated CNOs has not been aggregated, it makes sense that this differential would apply to executive salaries as well.
Healthcare systems that employ 10,000 or more workers pay the highest salaries to chief nursing officers and other senior executives.
The average salary for CNOs is $136,250, a benchmark most chief nursing officers hit sometime during their fifth year of continuous employment. A chief nursing officer position is a salaried position with periodic pay raises: The longer you stay at a job, the higher your salary will be. If you stay at your job for more than five years, in other words, you will earn more than the average salary.
As we have seen above, chief nursing officer salaries vary greatly from state to state. If you are looking for a bigger CNO compensation package, you have the option of moving to a state where average CNO earnings are higher.
Demand is high for chief nursing officers. The Bureau of Labor Statistics doesn’t specifically break out the position of “chief nursing officer” from other nurse executives, but the nurse executive management sector is projected to grow 32 percent between 2020 and 2030.
The demand for chief nursing officers is projected to grow more rapidly than the average occupational growth rate because:
Seventy-three percent of the nation’s chief nursing officers are over the age of 40. It is likely that in the next 10 to 15 years, many of these CNOs will be looking at retirement. Replacements will need to be found for the positions these CNOs are vacating.
The Baby Boomer generation is aging. By 2050, the number of senior citizens in the U.S. is projected to be more than 83 million—nearly 30 million more than in 2020. Senior citizens are disproportionately large utilizers of healthcare nursing services. Chief nursing officers will be needed to help coordinate those healthcare nursing services in a cost-effective manner.
The 2010 Affordable Care Act increased access to healthcare for other demographic segments as well, which means the utilization of healthcare nursing services for everyone is likely to increase. Again, chief nursing officers will be needed to help coordinate the utilization of these services in a cost-effective manner.
As the utilization of healthcare nursing services goes up, however, the number of nurses available to provide these services is projected to go down. Some experts predict that the U.S. will be short half a million nurses by 2030. Creative solutions will be needed to cope with a dwindling workforce, and such solutions are most likely to be developed and implemented by forward-thinking chief nursing officers.
The pay-for-performance reimbursement model for healthcare costs emphasizes value over volume. Simply put, this model offers hospitals and other healthcare providers financial incentives for enhancing the quality, efficiency and affordability of the healthcare they offer. Increasing quality while holding costs steady is a formidable undertaking indeed, and it will take the ingenuity of seasoned chief nursing officers to help pull it off.
The 10 states with the highest demand for chief nursing officers are California, New York, Texas, Florida, Georgia, Ohio, Tennessee, Arizona, Illinois and Massachusetts. Six of these states—California, New York, Texas, Florida, Georgia and Ohio —are also among the states with the highest Medicaid enrollment. This is not surprising: Medicaid expansion is correlated with the increased utilization of hospital services, and escalating utilization of hospital services will increase the demand for high-performing chief nursing officers.
| Rank | State |
| 1 | California |
| 2 | New York |
| 3 | Texas |
| 4 | Florida |
| 5 | Georgia |
| 6 | Ohio |
| 7 | Tennessee |
| 8 | Arizona |
| 9 | Illinois |
| 10 | Massachusetts |
If you make it to the interview stage of the chief nursing officer application process, you are doing well because only 20 percent of all job applicants do. The answers you give to most interview questions should not be longer than two minutes; remember your prospective employers will already have read your resume. You will have a definite advantage if you are an internal candidate applying for a chief nursing officer position at a medical facility where you already work. Here are some chief nursing officer interview questions you’re likely to run into.
This is a standard question during interviews for all executive positions, both in and out of the healthcare field. It might help to brush up on your notes if you took any classes in nursing leadership styles. The leadership style that works best is the one that fits the culture of the medical facility where you’re interviewing, so you’ll need to do some homework on that as well. And obviously, you will not parrot the answer below but talk about the leadership style that works best for you.
“I would describe my leadership style as ‘adaptive.’ The healthcare environment is constantly changing, and I think effective leaders need to acknowledge that fact by remaining flexible and modifying their leadership style based on the organization’s needs at any given moment. On the whole, I favor collaboration over dictates. I focus on encouraging professional growth because I think that’s the secret to organizational success.”
This question is designed to cut straight to the chase since staffing-related issues are one of the largest challenges that any chief nursing officer will have to tackle.
Even before the COVID-19 pandemic, nurse staffing was a huge issue for medical facilities: Patient censuses rise and fall, and there’s no reliable way to predict what the patient count will be on any single day. If you overstaff, you risk wasting money; if you understaff, patient safety will be imperiled. So, this question is really asking you to weigh cost-cutting measures against overall patient care and outcomes.
We are not suggesting here that you need to use this specific response. Obviously, you will answer the question by citing the strategic solution you think is most workable. But this is a useful way to break the question down: Give your general solution at the beginning of the answer; acknowledge the objections that some people may have with your solution by pointing out how their objections are not relevant, and then present a more specific solution to the problem.
“Safe staffing levels enable nurses to deliver higher quality care. It can also be viewed as a cost-saving measure because when staffing is adequate, costly nurse overtime expenses are greatly reduced and nurse retention rates are increased because nurses experience less burnout. The most effective strategy to deal with fluctuating patient counts, in my opinion, is to increase the number of per diem nurses who can be called in on an ‘as needed’ basis.”
This question (or one that’s similarly structured) is likely to be one of the top chief nursing officer interview questions because it tests your general knowledge of the general landscape of hospital nursing. Of course, the number of challenges hospital nursing faces is a lot higher than five, but citing a specific number in your answer allows you to focus on solutions to a smaller number of challenges while acknowledging that a larger number exists.
“In my opinion, the top five challenges that CNOs face right now include recruitment and retention of nursing staff as the nationwide nursing shortage increases; rising labor costs; the use of contract labor—including costly travel nurses—to nurse vacancies; declining reimbursements under the Affordable Care Act; and the development of performance metrics that can measure the attainment of national benchmarks set by the Centers for Medicare and Medicaid Services (CMS). To address recruitment and retainment issues, I would suggest…”
This question is designed to determine how you might prioritize the many responsibilities you will be assigned if you’re hired into a CNO position. Your answer should showcase your ability to implement strategies that reduce the medical facility’s risk while preserving a commitment to delivering high-quality healthcare.
“I believe the most difficult decisions are those involving staff reductions. Sometimes, however, when a medical facility is facing a severe budget shortfall, staff layoffs are the only answer. I would delegate the initial phase of the operation to the nursing directors and nurse managers who report to me by asking them to identify staff members whom they might cut if circumstances demanded it. Then I would do a cost-benefit analysis, identifying the costs that might be saved but also the benefits that might be foregone if any of the identified employees had special expertise in certain critical areas. I would use that final list as a guideline for any offboarding decisions I am asked to make.”
This is another question designed to determine how you prioritize challenges and rise to them. It’s the type of question that almost seems to invite a negative response along the lines of, “It was hard for me to…” But you should always avoid speaking negatively about anything in an interview context. A personalized response to this question will be the most effective response. Try to frame your answers about the specific ways that you rose to nurse leadership challenges.
“When I became a nurse leader, I missed the close relationships I developed with my patients as a clinician. I realized, though, that I was being given the opportunity to improve patient care in a new, expanded role. The transition from peer to leader also presented challenges because I was required to make decisions about nurse competencies and performance evaluations. I rose to this challenge by being as inclusive as I could and incorporating team decision-making as often as possible.”
Nurses are the largest group of professional employees in most healthcare situations. As their executive leader, chief nursing officers face a number of challenges. Here are seven of the most common and pressing obstacles that CNOs face.
Physicians, nurses and other healthcare professionals are managing an ever-increasing number of conditions and therapeutic interventions. Even before the COVID-19 pandemic, hospital patients as a whole needed more complex treatments than they’d needed even a decade before. Part of this is because the average length of stay—widely used as an indicator of efficiency—has gotten shorter so that only the most seriously ill patients end up being hospitalized for any length of time. Part of this is due to aging Baby Boomers’ need for care and rises in the incidence of chronic conditions like obesity and diabetes.
Hospitalized COVID patients required longer lengths of stay and more services than most patients utilized before the pandemic. Patients who’d put off treatment during the pandemic were also more seriously ill when they finally sought treatment.
Chief nursing officers must make sure that adequate nursing staff levels are maintained. Increasing nurse-to-patient ratios will help ensure that patients with complex treatment needs are satisfactorily cared for.
The looming nursing shortage was accelerated by the COVID-19 pandemic. A survey conducted by the high-tech research firm Research Triangle Park found that 67 percent of all RNs were considering leaving their position, their specialty or the nursing profession itself in the aftermath of the pandemic. Dissatisfaction was particularly high among Millennial nurses with two years or less of nursing experience.
To improve the recruitment and retention of nursing staff, chief nursing officers can implement strategies such as streamlining onboarding processes; providing more incentives like bonuses and comp vacation time; giving RNs more autonomy; decreasing documentation requirements; and establishing clearer lines of communication between hospital administrations and the nursing staff.
Even before the COVID-19 pandemic, labor expenses accounted for approximately one-third of all hospital expenditures. In the aftermath of the pandemic, clinical labor costs rose another 8 percent, driven by overtime expenses and the increasing use of traveling and agency nurses.
Chief nursing officers can’t tackle the rising costs of labor per se. But they can hire more per diem nurses who work on an “as needed” basis. Per diem nurses earn salaries but no benefits. Hospitals ultimately pay less for per diem services than they would spend paying overtime to nurses, or utilizing traveling and agency nurses.
Nurse burnout is the sustained state of physical, mental and emotional exhaustion that nurses reach when their work environment is too stressful. Work-related stressors include things like long hours, insufficient remuneration and the emotional strain of caring for patients who have poor outcomes. The most serious result of nurse burnout is a decrease in the quality of patient care. But nurse burnout also has serious economic implications for hospitals: The results of a study published in the October 2021 issue of The Journal of Patient Safety found that hospitals that invested in burnout reduction strategies spent 30 percent less per nurse per year than hospitals that did not invest in such strategies.
Chief nursing officers need to encourage the adoption of nurse burnout reduction strategies such as maintaining an adequate staffing ratio, minimizing the use of overtime, and encouraging nurses to take their vacation and comp time.
The rapidly aging nursing workforce is a major contributor to the nursing shortage. Nearly 40 percent of nurses in the U.S. workforce are 50 years of age or older, and actively contemplating retirement. These nurses will need to be replaced to maintain adequate staffing levels.
Chief nursing officers must encourage the organizations they work for to focus more efforts on nurse recruitment. Effective strategies include career advancement opportunities and mentoring programs for new graduates, offering flexible shift scheduling, and offering more comprehensive compensation packages.
Though some nurses do enjoy working off-hours, the majority of nurses working evening and night shifts are less senior nurses. As soon as these nurses acquire enough seniority to transfer to day shifts, they do so. This leaves evening and night shifts with a serious vacuum in nurse leadership.
Chief nursing officers must work with nursing directors and nurse managers to make sure that the schedules of swing shift and night shift nurses ensure plenty of rest between shifts. Hospitals have traditionally come down hard on night shift nurses who nap on the job, but forward-thinking CNOs might want to study whether short nap breaks could be a viable strategy.
Outpatient clinics not only pay nurses more than hospitals do on the whole, but they also offer more attractive Monday through Friday 9 a.m. to 5 p.m. shifts. In particular, nurses with specialized clinical skills are attracted by these outside employment opportunities.
This is a nursing problem that can only be tackled at the organizational level. However, chief nursing officers can encourage other members of the hospital’s senior executive team to stem the flow of departing nurses by improving patient staffing ratios and increasing compensation packages for nurses.
• American Organization for Nursing Leadership (AONL): With more than 11,000 members, AONL is the premier organization in the U.S. for executives, directors, managers, and clinical leaders. The organization sponsors a conference during the second week of April every year. Membership fees are $225 annually; benefits include a discounted subscription to The Journal of Nursing Administration and discounted continuing education credits.
• American College of Healthcare Executives (ACHE): ACHE’s 48,000 members all hold positions as professional healthcare executives. Its emphasis is more on physician leaders than on nurse leaders. The organization also holds an annual conference during the second week in April. Full membership dues are $345 annually.
• Organization of Nurse Leaders (ONL): ONL represents nurse leaders in Massachusetts, Rhode Island, New Hampshire, Connecticut, and Vermont. It has 1,100 members. Membership fees are $190 annually.
• American Hospital Association (AHA): AHA is an organization that represents more than 5,000 hospitals, health care systems, networks, and other providers of care. It has more than 43,000 individual members. Its primary mission is legislative advocacy. It’s also a well-respected source for information about the healthcare industry. Institutional dues are determined by the size of the organization while personal membership fees vary by professional affiliation.
• American Medical Group Association (AMGA): AMGA is a nonprofit trade association that represents the interests of integrated trade groups and multi-specialty medical groups. More than 175,000 physicians practice in its member organizations.
• American Nurses Association (ANA): ANA is a nonprofit organization dedicated to the advancement of the nursing profession. It has approximately 163,000 members and publishes two professional journals: American Nurse Today and The American Nurse. Membership is $180 annually; benefits include discounted continuing education classes and a job bulletin board.
• Why I Became a Nurse: Elizabeth Iro, the chief nursing officer of the World Health Organization (WHO), talks about what drew her to the nursing profession.
• NurseTV - Life of a CNO: This four-minute video explores a typical business day for Gudrun Moll, the chief nursing officer for San Diego’s Alvarado Hospital.
• Embracing Leadership Opportunities During Challenging Times: The team behind Nursing Management magazine talks with Kit Bredimus, the chief nursing officer at Midland Health in Midland, Texas, about how challenging times like the COVID-19 pandemic can actually turn into an opportunity for professional growth. Available on Spotify and Apple Podcasts.
• Lupe Ojeda, Chief Nursing Officer: The CareHero podcast team talk with CNO Lupe Ojeda about practical steps that you can take to move into nursing management and what a typical day as a chief nursing officer looks like. Available on Audible.
• A Productivity Practicum: An interactive course of study. Keith J. Gott elucidates the relationship between financial management and clinical delivery goals. The workbook delves deeply into performance metrics to familiarize chief nursing officers and other hospital managers with labor productivity management concepts.
What is it like being a chief nursing officer? Maria is employed as a chief nursing officer at a mid-sized hospital in a mid-western city. Here’s a look at a typical day on the job for Maria.
At least twice a week, I try to arrive at work at the beginning of the day shift so that I can sit in on nursing unit change-of-shift reports. Today, I sit in on 3-West’s report. 3-West is a unit that mostly handles pulmonary patients. I note that some of the nurses are concerned that their patients aren’t receiving their respiratory therapy treatments promptly. I make a note to have a chat with the medical director of respiratory care to see what can be done about this.
I meet with my executive secretary to go over my agenda for the day.
I go through my emails and voicemails. On any given day, their number easily exceeds 200. Some of the emails are communications on which I’ve been copied as a matter of courtesy, but others demand responses. My responses can’t be very long. I take notes on the voicemails and hand those notes to my secretary who incorporates the information into the appropriate files and arranges the meetings that need to be arranged.
Today is the hospital’s weekly budget meeting, chaired by the hospital’s chief financial officer (CFO). The CEO, the chief medical officer (CMO), the chief technology officer (CTO), the chief risk officer and various members of the hospital’s finance department are there as well. Today, we are continuing a discussion about whether we should commence building a new neonatal intensive care unit (ICN) or make structural upgrades to the ICN that already exists.
I go back to my office to follow up on the voicemails from earlier in the day that required phone calls.
I fine-tune a presentation I will be presenting at a national nursing conference the following week to which I have been invited as one of the keynote speakers.
I meet with the director of nursing and a team of nurse managers. They are updating me about disciplinary actions that have been brought against a handful of nurses in the past month for infractions of hospital policies.
A working lunch! I meet with the head of Family House, a nonprofit that operates temporary housing for the families of patients with chronic illnesses requiring long-term treatment. Qualifying families must live at least 50 miles away from the hospital, and most are low-income. We discuss ways that nurses can support the program more effectively.
A conference call with a group of CNOs from surrounding hospitals to brainstorm solutions to various issues that confront us collectively.
More paperwork. I review summaries of patient census counts and nurse staffing reports from all the hospital’s inpatient units to aggregate whatever trends I see.
Tomorrow is the quarterly meeting of our hospital’s board of directors. My presentation will be one of the centerpieces of the meeting since nurses play such a critical role in hospital settings, so I go over what I’m going to say one last time to make sure it’s informative, concise, and on point.
I make an unannounced visit to one of the med/surg units. I like making these impromptu visits; they give me a chance to see how different units operate at different times of the day. Today, I am pleased to see that things seem to be going very smoothly. I talk to nurses at the nursing station about whether they are satisfied with their nursing assignments (they are), and I even lend my hand at making a few beds with the nursing assistants.
Back in my office, I see that the CFO has emailed me some questions about the specific issues nurses are having with the existing ICN space. Since the CFO intends to incorporate this information into the presentation that he will be giving to the board of directors meeting tomorrow, I feel it’s important to supply him with this information as quickly as possible. It takes me a while to pull together the information from all my different sources.
I leave to go home at 5 p.m. This makes the day a relatively short one for me since often I’m here until 7 or 8 p.m.
This article has presented you with a comprehensive look at the role of chief nursing officer – what is it, steps to become, pros & cons, and salary. Just 11 percent of all nurses are interested in management positions, and only a small fraction of those are likely to be interested in nurse management at the executive level. A Chief nursing officer is a high-stress job with a huge amount of pressure. But for those individuals with a flair for leadership and an understanding of the American healthcare delivery system’s complex landscape, becoming a CNO can be a very rewarding career choice.
The chief nursing officer is an excellent career choice for a nurse who is efficient and organized, and whose commitment to improving healthcare extends beyond the patient’s bedside to all the complex operations that help a medical facility run smoothly.
Yes. Chief nursing officer is an increasingly competitive career track. To get hired as a CNO in the current job market, you’ll need the right education, experience, and certifications.
Seek employment at a medical center that has an internal nurse leadership program, and then do whatever you need to do to get enrolled in that program.
The three main duties of a chief nursing officer are ensuring compliance with government regulations and best nursing practices, budgeting and managing financial assets, and streamlining nursing efficiency within the healthcare organization as a whole.
The three main skills required to succeed as a chief nursing officer are time management, the ability to prioritize and business acumen.
The three main personality characteristics that contribute to success as a chief nursing officer are efficiency, accountability, and critical thinking.
The top three workplaces for chief nursing officers are medical centers, hospitals, and outpatient medical centers.
Chief nursing officers work with their medical facility’s CEO as well as with the chief administrative officer (CAO), the chief clinical officer (CCO), the chief medical officer (CMO), the chief financial officer (CFO) and other members of the medical facility’s executive team.
On paper, a chief nursing officer job may be listed as a 40-hour-a-week position. In actuality, however, CNOs frequently work far longer than that depending on what’s going on in a medical facility at any given time.
Chief nursing officers are not required to work holidays. Many CNOs may peek into the medical facility that employs them on a holiday, however, as a morale boost to the nurses they represent.
Yes, a chief nursing officer’s job can be very stressful because of the many responsibilities it entails.
There is no legal requirement to be certified to work as a chief nursing officer, but most employers prefer to hire certified candidates for this position.
The average chief nursing officer salary per hour is $70.76.
Yes, chief nursing officers make very good money. On average, CNOs make $147,182 a year, which is nearly three times the average salary for all occupations across the U.S. (($61,900).
| Chief Nursing Officer Average Annual Salary | All Occupations Average Annual Salary | Difference | |
| Number | % | ||
| $147,182 | $61,900 | +$85,282 | +137.77% |
California is the state where chief nursing officers make their highest salaries. In the Golden State, CNOs earn $89.75 an hour, $15,560 a month, or $186,670 annually on average.
| California | |
| Hourly | $89.75 |
| Monthly | $15,560 |
| Annual | $186,670 |
The Vallejo-Fairfield Metropolitan Area in California is the region where chief nursing officers earn their highest salaries. CNOs here earn $113.30 an hour, $19,640 a month, or $235,660 a year.
| Vallejo-Fairfield, CA | |
| Hourly | $113.30 |
| Monthly | $19,640 |
| Annual | $235,660 |
Chief nursing officers get paid considerably more than other nurses. On average, CNOs earn nearly two times the salary of other nurses.
| Chief Nursing Officer Average Annual Salary | All Occupations Average Annual Salary | Difference | |
| Number | % | ||
| $147,182 | $77,976 | +$69,206 | +88.75% |
Chief nursing officer jobs are extremely hard to get. It’s a highly competitive job market, and most employers prefer to promote internally.
Interim travel jobs for chief nursing officers occasionally become available.
There are few work-from-home jobs for chief nursing officers at medical facilities, but settings like insurance companies and nurse staffing agencies will occasionally let CNO be a remote position at least part of the time.
Jobs with similarities to chief nursing officer include nurse administrator, nurse manager, patient care director, and head nurse.
Five important leadership qualities that chief nursing officers should possess include the ability to act decisively, the ability to delegate effectively, critical thinking, attention to detail, and excellent communication skills.
No, an LPN cannot be a chief nursing officer. Only a registered nurse can be a chief nursing officer.
No, you must be a registered nurse to become a CNO.
A chief nursing officer’s reports typically include directors of nursing as well as the nurse managers who head up the units that provide various types of specialized patient care and services within a facility.
Within a medical facility’s hierarchy, the chief nursing officer is only outranked by the facility’s chief executive officer (CEO).
Within a medical facility’s hierarchy, chief nursing officer is the senior nursing position.
Assistant chief nursing officers help CNOs in strategic planning, resource management, financial planning, and the formulation of policies and procedures at the executive level.
Chief nursing officers are concerned with nursing operations within a facility as a whole whereas nursing managers are concerned with nursing operations within a hospital unit that’s dedicated to offering a specific type of patient care.
A chief nursing officer is in charge of nursing operations for an entire facility, whereas a director of nursing oversees patient care and nursing operations for a specific department within that facility.
A chief executive officer oversees all operations for a given healthcare facility, whereas a chief nursing officer oversees operations that pertain to nursing functions and reports to the chief executive officer.
A chief operations officer is charged with overseeing the operational functions of a medical facility on a day-to-day basis, whereas a chief nursing officer is charged with overseeing nursing functions within that facility. Chief operations officers and chief nursing officers share equal rank in the hospital management hierarchy.
Yes, CNOs can—and do—become hospital CEOs.
In a nursing home setting, a chief nursing officer can expect to earn $75.96. an hour, $13,170 a month, or $158,000 a year on average.
| Hourly | $$75.96 |
| Monthly | $13,170 |
| Annual | $158,000 |
In an assisted living facility setting, a chief nursing officer can anticipate earning $71.95 an hour, $12,470 a month, or $149,660 a year on average.
| Hourly | $71.95 |
| Monthly | $12,470 |
| Annual | $149,660 |
Yes, nurse practitioners can certainly choose to become chief nursing officers. Most don’t, however, because nurse practitioner is a clinical role, and nurses who choose that role do so because they love hands-on nursing practice. The chief nursing officer role is not a clinical role.
Yes, you can quit a chief nursing officer role without giving notice, but it would be extremely unprofessional of you, and you would never get hired into an executive management nurse role again.
Yes, chief nursing officers can be fired but this action would probably require a vote of the medical facility’s board of directors as well a decision by the medical facility’s CEO.
Yes, an RN can file a complaint against a chief nursing officer. Chief nursing officers are registered nurses, and a complaint can be filed with a state board of nursing against any registered nurse if the person filing the complaint has knowledge that an RN has violated that state’s nurse practice act or violated any other state or federal law.
Pattie Trumble, MPP, MPH
Pattie Trumble is a nurse who worked in both California and New York for many years as an emergency room nurse. She holds a Bachelor’s Degree in Economics from the University of California, Berkeley, and an Associate Degree in Nursing from the Samuel Merritt Hospital School of Nursing. After 10 years of providing direct care, she went back to school and earned concurrent Master’s degrees in both public policy and public health from the University of California, Berkeley. Thereafter, she worked for various public health agencies in California at both the community and state levels providing economic and legislative analysis.
