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From Bedside to CEO

Three of Philadelphia’s top hospitals are now run by nurses—who are also Penn alumnae. So what makes nurses such a natural fit for executive leadership?

When Regina Cunningham PHD RN AOCN FAAN, Gr’03, arrived for her first day of work as a staff nurse at Memorial Sloan Kettering in 1982, she had no idea that someday she’d be running a major hospital herself. It was rare, even unheard of, to see a nurse CEO back then. “It just wasn’t done,” Cunningham remembers. “I never even thought, at that age or stage of my career, about being a CEO. In fact, I didn’t think about it almost right up until it happened.”

Today, Cunningham is among a rising tide of nurses who are reaching the highest levels of leadership. As CEO of the Hospital of the University of Pennsylvania since 2017, she helms a top-ranked academic medical center with 807 beds and $2.8 billion in net patient revenue each year.

And as coincidence would have it, within only a few blocks’ radius from Cunningham, two other nurses hold similar roles. Next door to HUP, Madeline Bell RN, G’09, has been CEO of the Children’s Hospital of Philadelphia since 2015. A short walk past the Quad, you’ll find Karen Flaherty-Oxler, MSN, RN, GNu ’85, who was named executive director of Philly’s VA Medical Center last summer.

“Really good listening, good judgment, good assessment skills, the ability to read people,” Bell says, ticking off the qualities she believes make a strong leader. She adds: “They’re all things I developed as a nurse.”

From University City to Memorial Healthcare System in Florida, where three out of six hospitals are now run by nurse CEOs, to Johns Hopkins, where a former oncology nurse serves as president of the health system, to hospitals and health systems of all sizes throughout the country, nurses like Cunningham, Bell, and Flaherty-Oxler are increasingly landing at the top of the org chart.

Exact numbers are elusive, but in 2016, Becker’s Hospital Review spotlighted 33 nurses who had become CEOs of hospitals and health systems— and as the more recent appointments of Cunningham and Flaherty-Oxler illustrate, those numbers have only continued to grow since.

“It wasn’t like some mandate came down from the Joint Commission that you must hire nurses for these roles,” notes Kevin Mahoney, CEO of the University of Pennsylvania Health System. Rather, “I think the industry has had a growing recognition that nurse leaders can do more than just the clinical side—that they can run the whole ship.” “I think it’s been overdue,” he adds, but, “I’m glad it’s here.”

What Nurses Know

Bell had been working as a nurse at CHOP for six years when she began to consider leadership roles. “I was very curious about how decisions that impacted nurses and health care in general were made,” she says. “I decided I really wanted to be part of making those decisions versus having them delivered to me.”

Cunningham recalls a similar impulse to “improve the environment of care and make a better place for nurses to practice” emerging seven years into her own nursing career.

Both nurses say that as they pivoted into administrative roles and ultimately climbed to the top tiers of leadership, they were continually struck by how many of the skills they’d developed at the bedside directly translated to running hospitals.

Reflecting on this now, Bell mentions empathy first. “I think in general, people who choose nursing as a profession have a lot of empathy,” she says. “And that empathy for your patients and their families definitely helps prepare you to have empathy for your staff as an executive and a leader.”

Bell, Cunningham, and Flaherty- Oxler all credit nursing with instilling a strong sense of teamwork in them, too. “Functioning on a team is not always as easy as it looks,” Cunningham says, but as a hospital CEO in the increasingly complex world of health care, it’s essential. “You have to rely on a team where people have different roles and are bringing different expertise to the table,” she says, just as a clinical nurse does.

By working at the bedside, nurses also learn how to quickly form meaningful connections with their patients, and 

they perfect the arts of communicating complicated information and sharing difficult news. High-level executives face many of those same challenges. And nurses are explicitly taught to practice active listening, another skill that is, Cunningham says, “extremely important when you get into leadership roles.” As a nurse, “you also have a scientific mind and the ability to do assessments, understand results, and achieve quality outcomes,” notes Flaherty-Oxler—all things that translate directly to leadership. For all three alumnae nurse executives, clinical experience has proven invaluable, too. “I can talk shorthand with the clinicians,” Bell says. “I think that really helps. It gives me an advantage to really understand clinically the work

that we do.”

“To me, clinical knowledge is a differentiator,” notes Cunningham. “The work in a hospital is about taking care of patients, so having that clinical knowledge is very helpful.”

“A lot of times people ask me, how do you make decisions?” she says. “Many of my decisions go back to my formative years as a nurse—they’re focused on what the patient needs.”

Nurse Leaders Then and Now

While modern-day nurse CEOs are a fairly recent development, the practice of nurses running hospitals predates penicillin, X-rays, and even aspirin.

Patricia D’Antonio PHD RN FAAN, Gr’92—the Carol E. Ware Professor in Mental Health Nursing—traces nurse leaders back to 1873, when three nursing schools founded on Florence Nightingale’s principles opened in America. Similar programs quickly emerged over the next several decades, including at the Hospital of the University of Pennsylvania. By 1900, the US had somewhere between 400 and 800 hospital-based nursing schools. “One of the things people don’t realize is that the head of the training school was also the head of the hospital,” D’Antonio says. And that dual-ap- pointed leader was a nurse—including at HUP, where an English woman named Charlotte Marie Hugo was named both hospital superintendent and director of the nurse training program when the school opened in 1886.

“It was recognized that unlike physicians at the time, nurses were the ones who were onsite around the clock and had the best knowledge of the hospital’s day-to-day, hour-to-hour needs,” D’Antonio says.

Nurses continued to run hospitals through the early 20th century, but by 1920, things had started to change. With new technologies emerging, directing a hospital had gotten more complicated. Professional hospital administrators began to surface, taking over the head-of-hospital roles that had previously gone to nurses.

That shift continued well into the 20th century, as hospital operations became even more complex and “it was felt that a special set of business skills were needed,” D’Antonio says.

But over the last decade, nurses have been landing back at the top more and more.

Mahoney says the trend is partly linked to the growing number of nurses who are entering the field with bachelor’s, master’s, or even doctoral degrees. “When I started my career [in the 1980s], if you had a bachelor’s-prepared nurse, it was unusual,” he says. “Now, increasingly, our workforce is master’s-prepared.”

Advanced-degree nursing programs often incorporate leadership theory and training—including Penn Nursing’s own MSNs in Nursing & Healthcare Administration and Health Leadership— which means grads are better prepared to take the helm later on.

“I do believe you’re really well positioned by the science and art of nursing to flourish in leadership roles.”

—Karen Flaherty-Oxler MSN RN

The swell of master’s and PhD programs in nursing is also helping to propel more nurses into the C-suite as chief nurses, which in turn tees them up for even higher titles.

“Many nurses who are on C-suite teams as the chief nurse—which is what I was—are developing very strong administrative skills,” Cunningham notes. “They know how to make decisions within an organization and how to get things done.”

The rise of nurse CEOs also parallels the rise of women leaders in general. (While more men have been entering nursing, according to the last US Census in 2011, 91 percent of nurses were still women.) In 2019, nearly 22 percent of new CEOs named in the first half of the year were women—compared to just 12 percent over the same period in 2010, according to data from Challenger, Gray & Christmas.

“As women in society take on increasingly complex and responsible administrative positions, we see nurses doing so as well,” D’Antonio says. “I see it as an increasing acknowledgment that women are quite successful in these high-level executive roles.”

And finally, there are the emphases on value-based care and patient experience sweeping through health care in recent years.

“As we think about shifting from the volume-based, fee-for-service world to more value-based health care, there couldn’t be a better time for nurses to be at the helm of these organizations,” Cunningham says. “Nurses understand patients and nurses understand quality.”

“We’re starting to get an increased awareness of the importance of the patient experience to the entire healing process,” adds D’Antonio, “and in current hospitals, no one understands the patient experience better than nurses.”

What Happens Next

When a nurse walks into HUP for her first day on the job now, she’s surrounded by role models that Cunningham could never have envisioned 38 years ago—not only inside the hospital itself, but also nearby at both CHOP and the VA.

“The role models of nurse CEOs are really, really important for other nurses,” Bell says. “I’ve had so many nurses say to me, ‘I’ve seen you go from the bedside to being CEO, and it makes me realize I could do that, too.’”

It’s those role models who first cracked open CEO careers for nurses—and who will help the trend continue well into the future. “It’s a credit to the pioneers who were successful,” Mahoney says. “Otherwise the trend wouldn’t continue.”

Sue Keim—who directs both the Nursing & Healthcare Administration program and the Health Leadership program at Penn—says emerging educational programs ensure that nurses will keep reaching high-level leadership roles well into the future.

Keim notes that a number of universities in the US are beginning to offer leadership-focused DNPs—and in fact, come Fall 2021, Penn Nursing is on track to launch its own DNP in executive leadership.

“We’re going to expose students to higher-level health care finance and much higher-level leadership principles,” Keim says. “I have seen a growing trend in nurses who get DNPs in systems leadership becoming Chief Nursing Officers.”

Cunningham recalls a recent CEO summit she attended in Chicago, organized by the Association of American Medical Colleges and the Accreditation Council for Graduate Medica l Education. “There were 25 CEOs invited, and three of them were nurses,” she says. “That’s amazing.”

“I think that nurses will increasingly be considered serious contenders for these roles,” she adds.

That’s not to say that becoming a nurse guarantees you’ll someday run an organization, or even that you’d want to. “I don’t think being a nurse [automatically] makes you a great executive,” Flaherty-Oxler says. “But I do believe you’re really well-positioned by the science and art of nursing to flourish in leadership roles.”