NURSE 
PARTICIPATION 
HOSPITAL DECISION 
MAKING 
POTENTIAL IMPACT ON THE NURSING SHORTAGE 
Richard P. Kusserow 
INSPECTOR GENERAL 
OAI-0301120

OCTOBER 1988
 EXECUTIVE SUMMARY 
PURPOSE 
The puroses of this inspection were to (1) detenne the extent to which nurses parcipate in
hospital decision makng through representation on hospita governing bodes and key com
mittees and (2) describe techniques used by hospitals to retain and recruit nurses. This report 
presents our  makg. 
findigs on hospita decision  Hospital recruitment and retention techni
ques ar described in a separte report. 
BACKGROUND 
The demand for registered nurses (RNs) has fluctuated over the 
year -- from a shortage in the
1960s to a surplus in the mid-1970s and back to a shortge at the present time. Even though
80 percent of the nation s two milion RNs are employed
, hospitas ar now experiencing the
most severe shortage of RN s in recent history. Because 
of increased patient acuity, hospitals
need more nurses than ever before; at the same time
, more nurses ar choosing to work in
other health car settngs. Accordig to American Hospital Association (AH) 
sureys, hospi
tal RN vacancies more than doubled from 4.4 percent in 1983 to 
11.3 percent by December
1987. 
There is widespread agreement on the major factors which contrbute 
to the curnt shortage.
They include: 
salar compression and limited advancement opportunities; 
changing work schedules, including required night and weekend shifts, without 
adequate compensation; 
frustrtion due to having to cope with sicker patients and shorter stays; 
lack of recognition and respect for nurses as 
par of a professional health care team; 
lack of autonomy in makng patient care decisions; and 
fewer students opting for nursing careers because of expanded 
opportnities in other
professions. 
At an October 1987 hearg on the Nursing Shortage held by the Senate Finance Commttee 
Subcommttee on Health, witnesses from nursing and health 
car organizations cited low pay,
poor workig conditions and lack of input into maagerial decisions as issues faced by the
nursing profession. In December 1987
, Health and Human Services (HHS) Secreta 
Otis
Bowen appointed a special Commssion to study the nursing 
shortge and provide him with a  report and corrective action plan. The Commssion is headed by Carolyne K. Davis
, Ph.D.,
former Admistrtor of the Health Care Financing Admnistration. 
This inspection was initiated at the Commssion s request. It was conducted in two phases be
tween April and September 1988. Phase One was a telephone 
surey to chief executive of
ficers (CEOs) and chief nursing officers (CNOs) at a random sample of 93 hospitas 
throughout the U.S. Thiry-one hospitals were contacted in each of three 
strta: (1) hospitas
with 500 or more beds, (2) urban hospitals with fewer than 500 beds, and (3) 
rual hospitals

with fewer than 500 beds. Phase Two consisted of 
visits to a smal number of hospitals
around the 
countr which have developed strategies and techniques to recruit and retain nur
ses. This report presents the findings of the telephone surey. Results of the hospital visits
are contained in a companion report to be issued in the near future. 
FINDINGS 
The CEOs are the only members of hospita management who consistently attend 
governing body meetings. Over half of all CEOs are voting members
, while an
additional one-third parcipate in a non-voting capacity. 
One-third of CNOs attend governing body meetings regularly and another one-
third
attend when invited. Fewer than 2 percent of all 
CNOs vote. Similarly, while other
hospital management positions may sometimes attend governing body meetings 
, they 
rarly vote.

While one-fifth of governing bodes include 
nures from the local community, most are
selected for reasons other than their nursing backgrounds. 
More CNOs serve on planning and joint conference than on executive or fmance 
commttees. Five percent of CNOs are members of their hospital executive committees 
but none vote. Six percent serve on the finance commttee. 
Five of the six vote. 
In contrst, a CNO has a 50 percent chance of being on the joint conference committee, 
and one chance in thee of sitting on the planning commttee. Over half of the CNOs on 
these commttes vote. 
The majority of CNOs report diectly to CEOs. Most of the remainder 
ar one level 
down in the organization, reporting to either chief operations officers or executive vice 
presidents. 
According to CEOs, 57 percent of CNOs are paid more than other management officials 
at the same organizational level, and another 40 percent are paid the same. Only 3 
percent are compensated at a lower level.  Th-
quarers of CNOs indicated that nursing budgets ar prepared at the unit level 
while 18 percent prepare the budgets themselves. Eighty percent control the nursing 
budgets once approved 
Virually all CNOs control the hirng and firing of nursing staff. Nearly half have
delegated these authorities to the unit level. 
Nearly 60 percent of CEOs and 85 percent of CNOs believe that input into decision 
makng has a positive effect on nurse retention. Many view it as a relatively minor 
consideration, however, as compard to salares, educational benefits and autonomy on 
the unit. 
OBSERVATIONS 
While CNOs seldom vote on governing bodes, they do not appear to have been singled 
out for exclusion from governing body deliberations because, except for CEOs, very 
few other hospital management offcials are voting members. 
The status, autonomy and span of control of today
' s CNOs appear to be greater than 
the past. 
The majority of respondents believe, and we 
agre, that input into patient care and
management decisions result in a sense of control in the workplace and a stake in the 
success and well-being of the organization which should ultimately have a positive 
effect on nurse retention.  .............. ................................ ....................................... ................ ........................ ............. . .................................................. .....................................................................
............. .......... .... ....... ........ 
TABLE OF CONTENTS 
EXECUTIVE SUMMARY 
INTRODUCTION................................ 
Backg ro und.......................................................... 
............................................ 1 
Purpose.................................. 
Methodology..........  ................................................ 2 
FINDI NGS 

Nurse Participation in Hospital 
Governing Bodies................................ 
......... ............................ ....................... 3

Chief Nursing Officer Participation 
on Key Hospital Committees..........................................................................

Chief Nursing Officer Status 
and Autonomy in Hospital 
Hierarchy.............................................. 6 
Input into Decision Making as a 
Factor in Nurse Retention............................................................................... 9 
OBSERVATIONS ..................................................................................................... j 2

APPENDIX ...................................................... ........................................................ j 3

Characteristics of the Inspection Sample..........................................
 INTRODUCTION 
BACKGROUND 
The demand for nursing services has fluctuated over the years -- from a 
shortge in the 1960s
to a surlus in the mid-1970s and back to a shortage at the present time. Despite the fact that 
80 percent of the nation s 2. 1 millon registered nurses (RNs) ar working, hospitals are now
experiencing the most severe shortge of RNs in the history of the 
industr. Because of sig
nificantly incrased patient acuity, hospitals need more nurses than ever before; at the same 
time, more nurses ar choosing to work in other health care settngs. 
Sureys conducted
the American Hospital Association (AH) found that vacant RN positions more than doubled 
from 4.4 percent in 1985 to 11.3 percent by the end of 1987. 
Numerous factors have been cited as contrbuting to the hospital nursing 
shortge. Among the
most common are: 
salar compression and limited advancement opportunities; 
changing work schedules, including 
requird night and weekend shifts, without 
adequate compensation; 
frustrtion and burnout due to having to cope with sicker patients and frequent patient 
turover; 
little recognition and respect for nures as par of a professional health care team; 
perceptions that quality of car has suffered since the advent of the Medicare 
Prospective Payment System (PPS); 
lack of autonomy in makng patient care decisions; and 
fewer students opting for carers in nursing. 
Nurses have trditionaly been the lowest paid, least respected professional members of hospi
tal health car teams. In most hospitas, the chief nursing offcer (CNO) 
has not had equal
status with other hospital managers with comparable responsibilties. 
In Januar 1988, the
Wisconsin Organization of Nure Executives sureyed its membership to determne the extent
of nursing input to hospital boards. The 
surey found that 37 percent of nurse executives are
expected to attend board meetings regularly, and 41 percent 
ar expected to attend some or all 
hospita board commttee meeting  At a hearng on the Nursing Shortge held by the Senate Finance Commttee 
s Subcommittee
on Health in October 1987, witnesses cited low pay, unsatisfactory working conditions and 
lack of input in maagerial decisions as issues faced by the nursing profession. Some health 
care professionals believe that representation of nurses and 
nuring executives on hospital
governing bodes and key hospital commttees may have a positive effect on 
nure recruitment
and retention. 
In December 1987, Health and Human Services (HHS) 
Secretar Otis Bowen appointed a spe
cial Commssion to study the nursing shortage and provide him with a report and corrective ac
tion plan. The Commssion is headed by 
Carolyne K. Davis, Ph.  , former Admnistrator of
the Health Care Financing Admnistration. 
PURPOSE 
This inspection was initiated at the request of Dr. Davis. Its 
to (1) determine
puroses were 
the extent to which nurses are represented on governing bodes 
and policy-makng commttees
in hospitals around the countr and (2) describe strtegies and techniques used 
by hospitals to
recruit and retain nurses. 
METHODOLOGY 
The inspection was cared out in two phases. Phase One consisted of a telephone 
surey to
random sample of 93 hospitas selected from the 
universe of al Medicar-certfied acute care
non-specialty hospitas in the U.S. The sample contained thee strata: 
(1) hospitals with 500
or more beds, (2) urban hospitas with fewer than 500 beds and (3) 
rual hospitas with fewer
than 500 beds. Thiry-one hospitals 
were contacted in each stratum. At each hospital
, we in
terviewed the chief executive offcer (CEO) and the Chief Nursing Officer (CNO). We asked
each group questions on topics about which we thought they would be knowledgeable. This 
report contains the results of our telephone surey. 
Phase Two consisted of on-site visits to a small number of hospitals, most recommended by 
State Nures Associations, which have developed strtegies to 
attrct and retain nurses. The
results of Phas Two are presented in a companion report entitled, "
Hospital Best Practices in
Nurse Recrtmnt and Retention. 
Additional detal on the characteristics of our study sample appear in the appendix. The per
centages cited thoughout this report, 
unless otherwise noted, are weighted averages which rep
resent national projections of our actual sample findings to the universe of all 
Medicare-certfied acute care non-specialty hospitas in the U.  FINDINGS 
NURSE PARTICIPATION IN HOSPITAL GOVERNING BODIES 
The term governing body refers to the policy mang 
body of a hospita or other institution. It
may also be called the governing board, board of 
trstees, board of diectors or board of 
managers. In addition to establishing policy, the governing body is responsible for 
maitain
ing quality patient car and providig for institutional management and planning. 
Chief executive offICers are consistently represented on governing bodies. 
Chief Executive Offcers ar the only members of hospita management who consistently at
tend meetings of the governing body. Eighty percent of rual CEOs and nearly 90 percent of
urban CEOs ar represented on their hospital governing bodes. Overall, some 85 percent of
CEOs ar members of their hospital governing bodes. 
Accordig to CEOs, other hospital management positions, including executive vice-
presi
dents, chiefs of staf, chief operations/fmancial officers and CNOs 
ar occasionally repre
sented on governing bodes. 
Most chief nursing officers attend at least some governing body 
meetings. 
We asked CEOs and CNOs to characterize CNO 
parcipation in hospital governing bodies by
selecting one of 
thee options: (1) expected to attend regularly, (2) expected to attend when in
vited and (3) not expected to attend or 
parcipate. These categories ar simiar to those used
by the AH Center for Nursing in its 1988 Hospital Nursing Personnel Survey. The following 
char provides a breakdown of responses received. 
CNO ATTENDANCE AT GOVERNING BODY MEETINGS

CEO & CNO RESPONSES

(In Percentages)

CND Attnds  CND Attends  CND Does 
Regulaly 
When Invited  Not Attend 
STRTU  CEO  CNO  CEO  CNO  CEO  CNO
500+  51.6  58.  32.3  35.  16. 
Urban  34.  38.  37.  41.9  27.  19.4
Rural  34.  41.9  27.  32.3  37.  25. 
WEIGHTED 
AVERAGES  35.  41.5  32.  37.  31.9  21.6  Accordig to CEOs, 68 percent of CNOs are expected to attend governing body meetings 
regularly or when invited. In contrast, nearly 80 percent of CNOs responded that they attend 
at least some governing body meetings. Apparently, CNOs feel that they have more oppor
tunities for diect input to governing body proceedings than expressed by CEOs. 
Chief executive offcers are usually the only members of hospital management who 
vote on
governing bodies. 
As shown in the following char, the CEO has one 
chance in two of voting on the governing
body. However, other hospita maagement officials, including the Chief 
Operations or Finan
cial Offcer (COO/CFO) and the CNO, rarely vote. 
VOTING MEMBERS OF HOSPITAL GOVERNING BODIES

MANAGEMENT POSITIONS IDENTIFIED BY CEOs

(In Percentages) 
CEOs  CNOs  COOs/CFOs 
Members Vote  Members Vote  Members Vote 
STRATUM 
500+  83.  48.4 
12. 
Urban  93.  69.  10.3  20. 
Rur 
79.3  37.  10.3  3.4  13. 
WEIGHTED 
AVERAGES  86.  53.  10.3  1.8  17. 
Few governing bodies have nursing advisory 
committees. 
Governing bodes in urban hospitas and large 
ru  hospitals ar twice as likely to have a nursing
advisory commttee as  hospitals. Thireen percent of large hospitals and 14 percent of
urban hospitals reported that their governing bodes have 
ru  nuring advisory commttees, com
pared with 7 percent of 
hospitas. Overal, 10 hospitals, just over 10 percent of the sur
vey respondents, have such commttees. Thre of the ten, al with over 500 beds, 
are affiliated
with nursing schools and are therefore required to have nursing advisory 
commttees by the
Joint Commssion of Accrtation of Healthcar Organizations. 
Community nurses occasionally serve on governing bodies. 
One-fifth of governing bodes include nurse members from the 
local community. However.
most are selected for reasons other than their nursing backgrounds. We asked CEOs at 
hospI
tals with no local nure on the governing body whether they had ever 
considere recommend
ing that one be appointed. Eleven percent
, most of them in urban hospitals, said they had 
considered this.  Some respondents commented on this issue. The CEO at a large 
hospita stated, "We have 
considered appointig a community nurse to the Board, and ar now tring 
to identiy a per
son of the right statue." A rual CEO said, "The most importt consideration in the selection 
of board members is their managerial ability. That s a problem with nurses tody; they are not 
taught managerial skils. " Severa respondents indicated they had not considered appointing a 
nurse from the local community because board members 
ar appointed by local or State 
government officials. 
NURS OFFICER PARTICIPATION ON KEY HOSPITAL COMMITTEES 
CHIEF  ING 
Respondents were asked to identiy the most influential commttees in their hospitals, and 
then to indicate whether the CNOs were members and if they vote. The 
commttees named 
most frequently were executive, finance, planning and joint conference. 
All ar commttees of 
the governing body. 

While few chief nursing officers are represented on finance and executive, they more fre
quently serve on joint conference and planning committes. 
The executive commttee is the senior commttee of the governing body and may itself be a 
ruling body. Nearly 5 percent of CNOs serve on executive commttees, but none vote. 
The fmance commttee is responsible for managing the hospita' s fiscal affai. It monitors 
and approves hospital operating and capita budgets. Thre-quarers of CEO respondents iden
tified finance as an influential commttee. About 6 percent of CNOs serve on this committee; 
fewer than 5 percent vote. 
In contrst, 37 percent of CNOs ar members of the planning commttee. The planning com
mittee formulates the hospital's strtegic plan. It develops both long- and short-term objec
tives affecting internal and external hospita 
affais. Overal, nearly one-quarer of all CNOs
vote on the planning commttee. 
Similarly, CNOs have a 50 percent chance of serving on the joint conference 
commttee. 
More than one-thd of al CNOs ar voting members. The joint conference commttee 
provides a forum for the discussion of medical affai. It 
is composed of governing body 
members and medcal staf. 
The char on the following page presents additional detal on CNO 
paricipation on key hospi
tal commttees.  CNO PARTICIPATION ON INFLUENTIAL COMMITTEES 
Committee  Times Named  CNO Member 
CNO Votes 
Finance 
Executive 
Planning 
37.  23. 
Joint Conference 
50. 
35. 
CHIEF NURSING OFFICER STATUS AND AUTONOMY IN HOSPITAL 
HIERARCHY 
The majority of chief nursing officers report to the chief executive 
officer. 
Seventy percent of CNOs indicated that they report 
dictly to 
CEOs. Based on their verbal
responses, CNOs in rual aras report diectly 
to CEOs more than twice as often as their 
counterpars in urban hospitas with 500 or fewer 
beds.

Nearly half of the respondent hospitals also provided copies of their 

curnt 
organizational
chars. A review of these char showed nearly 60 percent of CNOs reportng to CEOs 
percent reportg to second level management. Over 70 percent  and 38
ar at 
an organizational level
equal to or higher than the chief fmancial offcer. 

Additional detai based on our review of

hospital organization chars is provided below. 
CNO LINES OF REPORTING 
(N=45) 
Reports 
Reports to  Other
to CEO  2nd level Mgmt
STRATU

500+

Urban

Rural

TOTALS 
(57:8%)  17 (37.8%)  (4. 4%)  Most chief nursing officers are paid as much as or more than their management counter
parts. 
Based on CEO responses, some 57 percent CNOs 
ar paid more than as other hospita manage
ment offcials at the same organizational level and 39 percent are paid the same. Only 3 per
cent are compensated at a lower level. 
Half of chief nursing officers supervise non-nursing deparents. 
About half of CNOs in each strtum supervise non-nursing as well as nuring services. Those
deparents cited most frequently ar social services/discharge planning, quality assurce 
rehabilitation and pharcy. Others include housekeeping, central supply, home health 
educational services and infection control. As shown below
, nearly one-quarer of CNOs su
pervise four non-nursing services, while 10 percent supervise either one or two non-nursing 
deparents. 
NON-NURSING SERVICES REPORTING TO CNO 
(In Percentages) 
Number of Services 
STRTUM 
500+  51.6  16.  22. 
Urban  51.6 
25.
Rural  45.  12.  29. 
WEIGHTED 
AVERAGES  51.2 
24. 
Forty percent of chief nursing offcers are masters prepared. 
As shown on the following page, over 40 percent of CNOs have masters degrees and 3 per
cent have doctora degrees. The CNOs in large and urban hospitals tend to have more forml 
education than CNOs in rual hospitals. One-fifth of CNOs in large hospitals have PhD 
degrees. Most CNOs with associate degrees or nuring diplomas ar in rual hospitals.  CNO EDUCATIONAL LEVELS

(In Percentages) 
Diploma  BS/BA  MS/MA  PhD 
STRATUM 
500+ 
12.  64.  19.4 
Urban 
12.  22.  61.3 
Rur 
16.  32.  32.3  19.4 
WEIGHTED 
AVERAGES  21.4  26.  41.8 
The CNO educational levels for large hospitals and urban hospitals in our 
surey compare

favorably with results of the 1985 annual 
surey of the American Organization of Nurse Ex
ecutives (AONE), whose membership consists primarly 
of CNOs from large hospitas in
urban areas. In that surey, 59.8 percent of the respondents held masters degres while 2.
percent had completed their PhDs. 
As a group, CNOs have fewer advanced degrees than CEOs. According to their own respon
ses, 60 percent of CEOs are masters prepared
, while 4 percent have doctoral degrees. 
Nursing departments prepare and administer their own 
budgets. 
Overal, nearly the-quarers of CNOs contacted indicated that 
budgets are prepared at the
unit level and reviewed by the CNO. Eighteen percent reported that they prepare the nursing 
budgets themselves. Nine percent, mostly in 
rual hospitals, do not prepar their own budgets.
Additional detal is provided in the following char. 
NURSING BUDGET PREPARATION 
(In Percentages) 
n=93 
Units Prepare  CND  Neither 
CND Reviews  Prepares  Prepares 
STRTU 
500+  93.

Urban  83.

Rural  58.  29.  12.

WEIGHTED

AVERAGES  72.4  18.
 Eighty percent of CNOs control nursing budgets once approved, and can reallocate funds 
among line items as needed. In large hospitas, all CNOs control the approved nursing 
budgets. 
Chief nursing officers control hiring and firing 
of nurses. 
Responsibilty for hirng and fing 
nursing personnel clearly rests within the nursing depar
ment. Nearly half of CNOs have delegated hirng and fIring authority to the unit 
level. One
quarr have also delegated authority to negotiate salares to the unit level. 
Hirng and fuing is done at the unit level in nearly 90 percent of large hospitals and about two-
thirds of urban hospitals. In rual hospitals, this authority generally rests with the CNO her
self. One rual CNO in a very small hospital is also the head nurse of the hospita' 
fig  s single 
unit. She does not have  authority. The one CNO in a large hospital who does not have 
firng authority attrbuted this to the provisions of the hospital' s union contract. The char 
below provides additional detai on 
hirng and fuing authority. 
HIRING AND FIRING AUTHORITY 
(in Percentages) 
N=93 
Unit  CND  Unit/CND Hire 
Hires/Fires  Hires/Fires  Can t Fire 
STRATUM 
500+  87. 
. 9. 
Urban  64.  35.5 
Rural  25.  71.0 
WEIGHTED 
AVERAGES  47.  50.  1.7 
INPUT INTO DECISION MAKING AS A FACTOR IN NURSE RETENTION 
Most respondents think nurse input into decision making is important. 
Nearly 60 percent of CEOs and 85 percent of CNOs believe that input into decision making 
has a positive effect on nurse retention. Many respondents indicated that this is just one of 
many factors, however, and not as important a consideration to RNs as salares, 
educational 
benefits and autonomy on the unit.  The following quotes ilustrate the range of opinions expressed by 
CEOs on the relationship 
between nurse parcipation in decision makg and retention. 
Unless nurses feel they have some control over their occupational functions, why 
would they stay? I'm not the best person to say how to deliver care 
effectively. I can
say, 'these are our financial restrictions, ' and then ask nursing, ' what can we do within 
them?' 
My goal is to have an RN on the Board of Trustees and expand nurse 
participation to
the executive committee. Nursing is half of the hospital staff and 90 percent 
of the 
patient care is delivered by RNs. They want and deserve more representation. 
Today s RN is not the same as 5-10 years ago. Toda, RNs reflect the  all
values of 
women in the workforce. They want and need 
participation and control in the
workplace, and are no longer wiling to accept physicians
' orders without question. 
1 question the logical link between job satisfaction 
and participation in decision 
making. In my mind, the two are independent variables. 
Money is the main thing. Once that is satisfied
, there is no diference between nursing 
and any other job. What keeps nurses on their job is the same thing that keeps other
people on their jobs. If the job is mae more attractive, more people wil want to do it. 
The two factors are absolutely not related. People leave for other reasons. The big
issue is money. Nurses are already 
part of decision making. 
Nurses are at a lower level where participation in hospital decision 
making just doesn 
interest them. "

Ifnurses are involved in decision making, it should be in the nursing department, not
on the governing body. 
Nurses are a very mixed up bunch of ladies who aren t interested in anything but 
money. They feel the hospital is there to provide them with a job, not to provide a ser
vice to the community. 
The CNOs also commented on this issue: 
Nurses remain in organizations with healthy assertive nursing 
departents where they 
participate in decision making. Hospitals with low turnover and vacancy rates are al
ready using nurses on decision making bodies. 
There is a relationship, bur' even with a voice in decision making, patient care nurses 
wil still get frustrated and burn out because it 
s simply a tough job.  , .
I'm not sure there is a relationship. Nurses do need more input into things that 
affect 
their own lives, but is that hospital decision making? It is more important to move 
decision making to the unit level and to seek input from 
staf nurses on how they can im
prove their own work as well as patient care. 
All other things being equal, the major 
factor in nurse retention is autonomy in their 
clinical practice. "

They like participating, but other factors, such as money and recognition
, are more im
portant in retention. 
Staff nurses want to serve on patient care and 
nursing practice committees. 
Thre-
quarers of CEOs and over four-fifths of CNOs thin that staf nures are 
interested in 
serving on commttees, paricularly those dealng with patient 
care and nursing practice issues.
Fewer nurses are interested in commttees not dictly 
work-related. Once on a committee, 
nurses continue to be interested if they believe that their 
parcipation can make a difference in
hospital policies or procedurs, and they see 
a positive effect on their practice. Thee CNO 
comments ilustrate the range of opinions expressed. 
A nurse s control over her environment and sense of self-esteem are enhanced by serv
ing on a committee. To many nurses, committee membership is as important as 
salaries. " 
Nurses don t realize how complex some issues can be. They agree to serve on a com
mittee thinking it wil lead to a better work environment or enhance their clinical prac
tice. Then they get bogged down in issues they are not interested in. 
The issues they 
feel are important are so far down the agenda, they wil never see the light of 
day. This
can be extremely frustrating. " 
It really depend on the 
person. Most nurses just want to do their jobs and don t want
to get involved. If they di get involved, they would get more job satisfaction. "  , .
OBSERVATIONS

We found that while most CNOs paricipate to some degre in hospital 
governing body meet
ings, very few vote. It does not appear, however, that CNOs have been singled out for ex
clusion from governing body deliberations which are open to other 
comparble management 
offcials, because other hospital management offcials (except for CEOs) are 
rarly voting 
members. There is no indication that the percentage of votig CNO members wil increase 
significantly in the near futur. 
Chief nursing officers are seldom represented on the two hospital 
commttees where business 
and financial matters are discussed -- executive and finance -- but do 
parcipate in substantial 
proportons on the planning commttee. Not surrisingly, there is also a high degre of repre
sentation on commttees which have 
trditionally dealt with patient care issues which have al
ways been nursing s primar concern. 
The status, autonomy and span of control of tody 
s CNOs appear to be grater than in years
past. The majority ar at the level of vice-president in the hospital organization, reportng
dictly to the CEO. Half supervise non-nursing as well as nursing services, and the majority 
are paid as much as or more than their organizational counterpars. The CNOs control nursing 
budgets and the hirg and fIring of nursing staf. In large hospitals, these authorities have 
furer 
been  delegated to the unit level. These improvements in status may reflect hospitals 
increased awareness of the critical role of nursing, but may also be the result of the efforts of a 
more sophisticated, better educated and better organized nuring profession. 
Most respondents believe, and we agre, that input into decisions -- whether related to the care 
of individual patients, nursing policies and practices, or the hospital' 
s futue -- provides nurses 
with a sense of control over their work and a stake in the success and well-
being of the or
ganization as a whole. The Deparent may wish to consider furer 
longitudinal research as 
a means to obtai definitive data on the impact of parcipation in decision makng on nurses
employment decisions.  APPENDIX 
CHARACTERISTICS OF THE INSPECTION SAMPLE 
Hospital Universe and Respondents by Stratum 
Stratum	 Universe  Respondents

of Hospitals  CEOs  CNOs

500+ Beds  369

Urban  686

Rur 
718

Totals	 773 
II.  Hospital Classification by Stratum (n=93) 
Stratum  Government  Non-Gov  Investor 
Notfor Profit  Owned 
500+	 16.  80. 
Urban	
77.4%  12.
Rur	
41.9%  45.  12. 
Weighted

Averages  25.3%  62.  12.3%

III. Other Characteristics 
Eighteen (19.4 percent) of the sampled hospitals 
ar religiously aff1iated. Eleven of 
ar 
these  Catholic. 
Rural hospitas reported a mean vacancy 
2 percent while the mean rate for 
rate of 13.
both uran and large hospitals is slightly over 12.6 percent. Overall, the mean vacancy 
rate is 12.9 percent 
Eleven hospitals (11.8 percent) reported vacancy rates in excess of 25 percent. Seven of 
these are small hospitals in rual areas. Only one hospital has over 500 beds. 
Just over 40 percent have experienced a rise in vacancy rates and the s
ame percentage
have reduced vacancy rates durng the past year. The remainder have)jtayed constant.