Leading the WayNursing LeadershipStaffingWorkplace Management

CNO-CFO collaboration for safe nurse staffing

By: Pamela Cipriano, PhD, RN, NEA-BC, FAAN, and Todd Nelson, FHFMA, MVA

Steps for building a partnership.


  • Collaboration between chief nursing and finance officers builds trust and is essential to address the challenges of balancing the resources needed to provide quality care and support other operations.
  • A shared understanding of the issues and stressors facing nursing and finance leaders guides mutually agreeable decisions for optimal nursing resource allocation.
  • Nursing and finance colleagues who have developed effective working relationships have successfully navigated the COVID-19 crises with open communication, mutual respect, showing passion for the organization’s mission, and a commitment to teamwork.

Since the early 1900s, when nursing students traded labor for learning, some would say hospitals have never had enough nurses. “Staffing for nursing service looms as a major problem to most nursing service administrators….What should be the ratio of nursing personnel to patients? How much nursing care does each patient need per day?” These comments from a nurse leader in 1952 ring true today, yet the methodology for determining optimal staffing continues to be challenging given care complexity and individual nurse characteristics.

Safe staffing levels top the list of nurses’ concerns because they know the indisputable relationship between appropriate staffing and patient safety. Nurses also know that insufficient staffing puts them at risk for fatigue, missed care, and moral distress. At the same time, the continuing pressure on healthcare organizations to reduce costs while still providing high-quality care puts a target on labor, and nurses make up the largest portion of the workforce. Finding a solution to balance the expenditure of resources for quality and safety with a positive work environment for the healthcare team requires a strong positive relationship between nursing and finance leaders.

Cost and quality interests need not compete. Nursing and finance leaders share the goal of delivering care that achieves optimal patient outcomes. When they work together, they can find the balance between mission and margin to improve quality and safety while ensuring financial sustainability.

The American Nurses Association (ANA), American Organization of Nurse Leaders (AONL), and the Healthcare Financial Management Association (HFMA) issued a report, The Business of Caring: Providing Optimal Allocation of Nursing Resources, to address outcome-based staffing and to highlight successful productive working relationships between chief nursing officers (CNOs) and chief financial officers (CFOs), who promote a shared understanding of the issues related to nurse resource allocation and financial stewardship. The report emphasizes a patient-first interprofessional approach to improve nurse staffing and the value of patient care.

What follows is a recap of the principles for establishing productive working relationships and action steps to promote optimal staffing. Feedback from several CNOs and CFOs who are dealing with the ravages of the COVID-19 pandemic describe the challenges of providing staffing under crisis standards while simultaneously mitigating the financial crises threatening their organizations’ economic stability.

Contemporary collaboration

Historically, nursing care was considered a cost, which frequently led to a quasi-adversarial nursing-finance working relationship. Today, nurses are recognized as assets. Several studies have demonstrated the relationship between increased nurse staffing and improved patient outcomes, particularly in decreased preventable hospital-acquired conditions, mortality, and hospital readmissions. The ANA established a business case demonstrating that increased nurse staffing levels in acute care hospitals not only improve care quality, but also result in a positive fiscal impact for hospitals based on improved quality outcomes and decreased lengths of stay.

Interprofessional nursing-finance teams benefit from the same trust and respect expected among clinical teams, starting with an understanding of one another’s work and challenges and adopting best practices. The team can begin by affirming that the top priority is to improve quality and safety. Nurses can demonstrate the value created by linking quality and cost improvements by inviting finance colleagues to round with them and showing how nurses keep patients safe, thus preventing harm and added expense. Finance colleagues can explain what’s important to fulfill their role in quantifying cost improvements that convey the impact of quality and cost.

Next, develop a shared vocabulary that defines key terms used by each discipline; this helps create common understanding about the work needed to deliver care or demonstrate cost improvements. Words that evoke a negative response, such as “nonproductive time,” should be replaced with a description of functions that fulfill professional practice expectations.

Finally, consistent and accurate data build trust. Nurses increasingly drive quality improvement, including generating, collecting, and analyzing outcomes data. Finance and administrative personnel have parallel responsibilities to ensure accurate, reliable, and timely data about the organization’s resources. The synergy of both groups working together creates a deeper trust and understanding of the relationship between cost and quality.

Stress threatens relationships and teamwork

Every worker faces different stressors arising from cost and quality pressures that can remove joy from work, strain relationships, and threaten the effectiveness of team members. In addition to care delivery, staff nurses, nurse managers, and nurse executives must address ever-growing responsibilities, such as reducing length of stay, coordinating smooth transitions, performing electronic doc­umentation, reporting quality metrics, ensuring a healthy work environment, advocating for resources, addressing workforce shortages, and demonstrating compliance with myriad policies.

Finance professionals face the challenge of adhering to regulatory requirements; tracking changing payment models; and addressing the rising costs of pharmaceuticals, supply chains, and technologies, while also implementing cost-reduction strategies that won’t diminish quality.

Understanding these unique stressors and working together to address them helps reduce conflict and maintain a focus on the patient experience.

Action steps

The struggle to balance quality outcomes for patients and staff with efficient operations and total cost of care affects nurse staffing decisions. ANA, AONL, and HFMA advocate for evidence-based nurse staffing approaches that consider a variety of factors, including patient acuity, patient turnover, nurses’ skills and experience, and other team members’ support.

Many organizations have relied on internal budget targets rather than systems that match patient needs with the education, skills, and experience of those who deliver care for determining nursing resource investment. More effective methods continue to evolve that incorporate patient acuity measures into workload management systems that include forecasting, scheduling, analysis, and feedback. Teams can adopt action steps to improve their resource allocation methods. (see Take these 5 steps.)

Take these 5 steps

These steps can help facilitate joint efforts between nursing and finance leaders and yield better nursing resource allocation.

  1. Pioneer creative nurse staffing approaches. Develop data-driven models that integrate patient needs and optimal skill sets, including flexibility to adjust shift to shift and make full use of other team members. For example, when additional ICU nurses are needed but not available, look to areas such as postanesthesia care for ICU-experienced nurses who might be reassigned to help. If patient volume is low in acute care, have those nurses work as an ICU nurse partner to help care for complex patients. Develop a transition team that can help expedite discharges or care for patients ready to go home but are awaiting transportation. Use student nurse technician positions or other support staff roles to help nurses so they don’t have to go in and out of rooms for information, supplies, and equipment.
  2. Assess new technology. Implement technology for increased efficiency and productivity, involving stakeholders to avoid unintended consequences.
  3. Work toward joint accountability. Develop true partnerships at all levels, from the C-suite to the frontlines, and embrace best practices.
  4. Agree on shared principles. Acknowledge that safe nurse staffing creates better patient experiences and outcomes and leads to employee retention.
  5. Promote interprofessional collaboration. Build key relationships by being open to new ideas and using a jointly understood vocabulary.

The ultimate pressure test

The COVID-19 pandemic has compelled us to work in unimaginable ways and to allocate resources creatively. Checking in with nursing and finance leaders in several states revealed a somewhat consistent pattern of the pandemic’s impact on hospital operations and responses. (See Pandemic’s staffing impact.)

Pandemic’s staffing impact


Nurse and finance staff in healthcare organizations across the country took similar staffing steps to prepare for a surge of patients with COVID-19. These strategies could be helpful for future pandemics.

  • Preserve personal protective equipment (PPE) and ensure safety; stop operating room and other procedures except emergencies.
  • Shut down outpatient routine services in primary care and specialty practices.
  • Shift multi-use practice locations to single use and prepare for additional capacity needs.
  • Authorize remote work and flexible schedules.
  • Secure PPE regardless of cost.
  • Establish command centers to plan for and execute operations.
  • Redeploy nursing and other staff to
  • support ICU teams caring for patients with COVID-19
  • shift from children’s care to adult care
  • perform COVID-19 testing.
  • End use of contract and travel staff.
  • Ask staff to perform duties they may not have done before; provide training first.
  • Scale up telehealth services.

For many hospitals, a precipitous drop in patient volume led to a significant loss of patient revenue. If hospitals received a surge of patients with COVID-19, their financial losses weren’t as great or were fully restored. As hospitals adjusted, their attention turned to other actions, including

  • improving systems for supply chain management and ensuring reliability and resiliency
  • providing childcare solutions to ensure staff could come to work
  • addressing increased rates of fear, stress, and burnout
  • supporting employees affected by racial injustice and protests
  • implementing discretionary cost-reduction measures.

For hospitals that suffered significant losses with limited recovery, financial mitigation measures included reduced pay and hours, furloughs or layoffs, suspended retirement benefit contributions, and cessation of annual pay increases. Alternatively, in those organizations experiencing patient surges, maintaining a clinical workforce presented different challenges that led to hiring additional staff and rewarding or incentivizing staff for working in crisis conditions.

Regardless of the situation, these CNOs and CFOs reported having a positive relationship with one another before the pandemic and that their overall C-suite team grew stronger throughout these experiences. They consistently praised one another for their openness, ability to resolve any disagreements, mutual respect, belief in the mission, and passion for the team. What is their advice for other colleagues to build a strong positive working relationship? Learn to speak the same language—understand and appreciate your partners’ perspectives, be a good listener, and don’t shy away from difficult conversations. Above all, strive to develop a relationship from day one. It could determine success in a crisis.

Fierce and fearless collaboration

On the mind of every finance professional has been decreasing costs, restoring revenue, and adjusting to a future system that provides more virtual care. Recovery has been slow in some areas, with emergency department visits lagging across the country and elective surgeries returning at different rates despite concerns that delayed care has put some patients at risk.

The most difficult decisions in the recovery and readjustment phase are those affecting human capital with tough choices that impact nursing and other hard-to-recruit roles. Hospitals that retained all their staff were better able to scale up again and address returning volumes of patients. Nursing, finance, and other administrative leaders are now faced with deciding how to address business needs where staffing must support services that can restore or grow revenue as well as prepare for a potential next surge and possibly make permanent some of the earlier redeployments.

The keys to a successful staffing strategy are teamwork and the empowerment of staff to share ideas and contribute to decisions. Our CNOs and CFOs lead this effort. They understand that massive disruptions require fierce and fearless collaboration and that caring for the care team is essential for staff well-being and critical to success. Being positive and projecting a sense of calm, showing empathy, and addressing employee health and safety lifts an organization in this time of crisis.  AN

To view a list of references, visit myamericannurse.com/?p=71895.

Pamela Cipriano is dean of the University of Virginia School of Nursing. Charlottesville. Todd Nelson is chief partnership executive at the Healthcare Financial Management Association in Westchester, Illinois.


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