Chief Nurse Executive prioritizes ‘voice of the nurse’ to improve satisfaction and retention

As Chief Nurse Executive at HCA Healthcare, Dr. Sammie Mosier leads nearly 100,000 nurses across 190 hospitals and 2,400 sites of care in 20 states and the United Kingdom. She began her career 28 years ago as a medical-surgical nurse at HCA Healthcare’s Frankfort Regional Medical Center in Kentucky, and built her experience through leadership roles with increasing levels of responsibility. Her path to leading the nation’s largest nursing workforce instilled in her a belief that listening to nurses is key to delivering excellent patient care.

Below, Sammie shares how she prioritizes the ‘voice of the nurse,’ including recent examples that resulted in development of new best practices in care delivery, as well as improvements in nurse satisfaction and retention. As a nurse leader who navigated a global pandemic and is actively addressing the national nursing shortage, she hopes to inspire other leaders to develop intentional vehicles that elevate nurse feedback to drive healthcare quality and innovation.

Related article: Federation of American Hospitals’ “Hospitals in Focus” podcast with Dr. Sammie Mosier

Voice of the nurse

Written by Sammie Mosier, DHA, MA, BSN, NE-BC

Throughout my career, I have focused on advocating for nurses to support their development and drive clinical excellence. This has become more important with the growing “Care Complexity Gap,” a decrease in expertise in the nursing workforce — when large numbers of retiring nurses are replaced by new ones — coupled with increasingly complex patient care due to an aging population and related comorbidities and chronic illness.

Our cornerstones for developing the nursing workforce and supporting nurse satisfaction plus retention include:

• Leadership and advocacy – Developing empowered leaders who can advocate and support care team growth and wellbeing
• Clinical education – Enhancing the clinical expertise of our care teams through skill-building and hands-on educational opportunities
• Dynamic care teams – Optimizing care team models to best match clinical expertise with patient needs
• Care-first culture – Championing a professional practice environment where care teams feel supported to deliver high-quality patient care

Across all of these foundational pillars of HCA Healthcare’s nursing strategy, prioritizing the ‘voice of the nurse’ at every level of our organization is key. Nurses are passionate about patient care, and they have an invaluable perspective. They advocate for patients and their voices influence positive changes for the practice of nursing, which ultimately improves care.

At HCA Healthcare, we actively listen to nurses in many ways, including through:

• Professional Practice Councils, where nurses make decisions about how we provide care
• Advisory Councils that govern how best practices are shared across the enterprise
• Resource Councils at divisions and hospitals that bring together key stakeholders to listen to nurses, solve operational challenges, drive engagement and elevate resources needed
• Coding for Caregivers, an annual event that pairs our nursing teams with IT experts to develop technology solutions that address nurse feedback on improvement initiatives
• Walk in Your World initiative, where corporate and division executives shadow nurses to gain insight into challenges
• Vital Voices, a continuous listening survey through which colleagues actively seek to solve problems and generate ideas

Every tier of HCA Healthcare’s organizational structure includes nursing leaders, from my role at the executive level to our clinical nurse coordinators, who represent the voices of front-line nurses.

Today I’m sharing three recently launched initiatives at HCA Healthcare that were developed based on nurse input. These programs are directly responsive to nurses’ needs — where they identified a gap, we investigated the need and together we developed, tested and scaled the solutions.

Clinical Nurse Coordinator Resource Tool

Shortly before the COVID-19 pandemic, we created HCA Healthcare’s clinical nurse coordinator (CNC) role as an elevated charge nurse role, to better support and represent the voices of frontline nurses. With an increasing number of new nurse graduates, we needed an infrastructure that would better support them in the face of the care complexity gap, while developing a pipeline for nurse leadership in an even more focused way.

Today this group of CNCs is 6,500-strong, comprising a majority of our frontline nurse leaders.

In the summer of 2022, we launched our CNC Advisory Council, which includes a clinical nurse coordinator from each of our 15 divisions and is representative of multiple service lines and geographical areas. As an important part of this pivotal meeting, our executive leadership team shared some of the ways HCA Healthcare learns from, innovates and improves care delivery across our organization.

It was during this convening of high-performing, passionate frontline nurses that we identified a need we knew could be somewhat easily addressed, due to our existing data and technology infrastructure.

We shared with the CNC Advisory Council a technology we developed during early onset of the pandemic, which showed us a real-time picture of COVID-19 patients across our organization, down to each individual hospital, unit and patient. This tool helped us (and the healthcare industry at large) navigate capacity to treat not only COVID-19 patients, but all patients in the many communities we serve across the country.

This particular example of innovation sparked an important conversation. Our CNCs said what they really needed was a way to identify in real time nurses who needed the most support. A simple, visual way to understand the current state of their units, while also treating their own patients.

They shared that if they had 10 minutes free, they wanted to help their nurses (and therefore patients) in the most meaningful way. They asked for insight into frequent tasks documented in the EHR to paint a clear picture of nurses who might need assistance, without them having to ask for it.

I thought, “right, we can do this.” And we did.

In conjunction with nurses, we developed our CNC Resource Tool to identify the ‘health’ of their units and individual nurses, especially to identify any nurse falling behind. This could be related to patient medications and many other tasks documented in the EHR. It was designed by CNCs, who helped determine how it looked and worked for easy integration into workflow.

Because of this tight collaboration with nurses, implementation and adoption were easy. There was a ‘pull not push’ dynamic due to a real need and appreciation for the tool. A differentiator for deploying the CNC tool so quickly is our existing technology. Foundationally, we had put things in place to support development of tools like this. We scaled it across the enterprise in just six months, and utilization remains high.

Currently it is primarily used by our CNCs, who leverage it to target key events during the day, including shift change. They use the tool to monitor patient medications, missing assessments and whether or not nurses have had their breaks, among many other checkpoints.

Additionally, our Clinical Support Coordinators (CSCs) — a newly developed role described below — use the CNC tool to see tenure of nurses to support new graduates. These leaders lean on the CNC tool during rounding to remove barriers, comparing number of alerts with a nurse’s history to best support each individual.

Our CNCs and CSCs are using this tool in ways we didn’t anticipate, and we’re hearing positive anecdotes from nurses about how it improves time management and satisfaction. All of HCA Healthcare’s 15 divisions had greater than 90% utilization of the CNC Resource Tool within the first month of their implementations, which is high for a tool not required for nurses to do their jobs.

It is helping us determine what is most useful to our nurse leaders and their units, and we continue to collect qualitative and quantitative data to improve it as we evolve what good looks like.

Our CNCs and CSCs say that the CNC Resource Tool is a ‘game changer’ for nurse support and retention.

Clinical Support Coordinator Role

Long a part of our commitment to supporting new nurses, HCA Healthcare’s Nurse Residency program is a 12-month transition to practice program that helps new graduates gain confidence and competence as they advance into their role as professional nurses.

In 2022, to further support new nurses, we created our clinical support coordinator (CSC) role. CSCs are highly experienced registered nurses who don’t treat patients, but rather are solely focused on supporting newer nurses for skill development, emotional wellbeing and more. The goal of the CSC role is to enhance high-quality, patient-centered care delivery by providing education, feedback and mentoring to newly graduated, first-year and new-to-specialty nurses.

These clinical support coordinators use a newly developed CSC Rounding Tool, which feeds directly into a real-time CSC Performance Dashboard to help CSCs monitor and improve the health of the units they support. Using the dashboard, the CSC then works with unit managers, directors and clinical educators to review trends in education and training, and escalate employees in need of additional support (emotional or educational).

We standardized and expanded our CSC Program over the last two years, creating a team of more than 300 CSCs. As a result, new graduate registered nurse (RN) and first-year RN turnover was lower in 2024 in departments with CSC support than in departments without.

• New graduate RN annualized turnover in 2024 was 14% lower in units supported by CSCs than without
• First-year RN annualized turnover in 2024 was 11% lower in units supported by CSCs than without

Additionally, we have seen significant improvements in nurse and physician satisfaction, as we moved from approximately 50 CSCs in 2022 to now more than 300 across our organization.

Because of HCA Healthcare’s commitment to improving systems of care, we have taken a unique approach to how we have scaled and operationalized the CSC role. This is key because, due to the Care Complexity Gap and pandemic, we have more new graduates on our floors than ever. And, now new nurses are going straight to intensive care units (ICUs), women’s & children’s units and other complex care units.

Here are some tactical ways we standardized and grew the CSC role to support our newest nurses.

• We recognized we needed enterprise standards for the CSC role in terms of:
  • Who they were supporting, so we defined this as support to nurses in first two years generally, nurses in first year at HCA Healthcare and nurses in first six months on a new unit
  • Emotional support as a new focused skill, so we worked to help CSCs develop these skills to fill their own and others’ needs beyond nurse leader business as usual
  • What good looks like, so we brought in nurse leaders and corporate partners to determine what constitutes good CSC practice and results
• We recognized that CSCs often are highly tenured with educator backgrounds, and that we and they would benefit from leveraging their expertise in more standardized way.
  • We made it easier for CSCs to support nurses with technology
    • Previously they had to record manually and individually the most common skills they supported, and number of rounds per month
    • We built a CSC Rounding Tool, a new technology that was informed by feedback from CSCs and nurse leaders to determine the right questions to ask
    • We made it easy for CSCs to identify who needs the most support with the rounding tool, which is accessible on their mobile device
  • We established new levels of visibility into how CSCs are improving nurse workflow, satisfaction and retention
    • We built a real-time, CSC Performance Dashboard for CSCs to monitor trends in the ‘health’ of their units as they support nurses
    • We worked with our clinical data and analytics team to build a compelling story around our nurse satisfaction and retention story, with access to new data points around CSC work
    • As a result we found that new graduate turnover was lower in facilities with CSCs, and nurse engagement scores improved when asked if they had “resources to do my job” on our Vital Voices survey

This new structure and data around the CSC role, along with qualitative feedback from CSCs and new nurses, helped me and my leadership team build our business case to double our number of CSC positions from approximately 150 to 330 in 2024.

Speaking of qualitative feedback, here are some things we hear from our hospital nurse leaders, CSCs and the nurses they support:

• “The CSC program is a huge nurse satisfier. RN turnover, first-year turnover and practicum conversion are all improving.”
• “We recently heard that new nurses were adjusting their schedules to work the shifts they knew we [CSCs] would be working. That means so much to hear that they value our support in that way.”
• “Having a CSC available is such a game changer. I truly value their help and guidance.”

As we monitor data and feedback around the CSC role, I can clearly see trends that will help address nursing workforce issues across the industry, including nurse retention. Importantly, this also means improving nurse satisfaction, and helping to guide fulfilling careers for new nurses who need support to love what they do.

Revive Code Blue App

Through another of our vehicles for listening to the ‘voice of the nurse,’ we addressed an opportunity to improve how nurses handle and record Code Blue events. Our Coding for Caregivers event pairs nursing teams with IT experts to develop technology solutions that address nurse needs and ideas for practice improvement. Our Revive Code Blue App is a Coding for Caregivers 2022 winner that allows nurses to electronically record a Code Blue event, improving upon the industry standard paper documentation process.

Understanding that they have an opportunity to improve systems of care across our organization by lending their voices to the conversations around improvement, nurses in HCA Healthcare’s North Texas Division helped identify that Code Blue paper documentation could be improved if standardized through direct-to-EHR technology. They noted that the manual paper process did not efficiently capture times, actions, medications and participants involved in Code Blue events.

Further, they shared that nurses often found themselves documenting Code Blue events multiple times, using multiple mediums before entering into the patient electronic health record, hindering care team collaboration.

Through their collaboration with IT teams, they helped to develop Revive, a mobile application that allows nurse documenters to electronically record a Code Blue event in real time. The goals for Revive were to increase efficiency of Code Blue documentation, reduce paperwork and duplicate documentation, streamline care team communication for the continuum of care and improve visibility of Code Blue data for analytical reporting.

As a result, Revive is an iPad application that digitally transmits Code Blue events to the EHR. It was selected by our division chief nurse executives as our 2022 Coding for Caregivers ‘Voice of the Nurse’ award recipient, based on scalability, usability, speed of implementation and user satisfaction.

Currently the Code Blue app is being used in 69 HCA Healthcare facilities, and another 58 facilities are expected to go live this year. Importantly, the feedback we’re receiving from nurses has been extremely positive.

• “Everyone wants to use it, everyone sees the benefit of this, everyone is saying ‘when can I have it?’ It is very encouraging.”
• “We received feedback today from a non-pilot ICU that received a patient from a pilot unit, noting that the ease of locating the code record and determining ‘the patient’s story’ was significantly easier.”
• “It took mere seconds as opposed to an arduous amount of time sorting through a paper record to understand the patient’s history.”

For me, this is everything. It’s what drives me every day: improving patient care by improving the capabilities, workflow and experience of the people who provide it.

Takeaways for healthcare leaders

I hope this inspires nurse and other leaders in healthcare to intentionally create avenues through which you can actively collect nurse feedback. These are our care team members closest to our patients, and when we empower them to lend their voices to improving patient care, we all win. This has been my experience, from being a frontline med-surg nurse to leading the nation’s largest nursing workforce.

I will continue to tirelessly advocate for the ‘voice of the nurse,’ and encourage you to do the same.

Thank you to our HCA Healthcare nurses who inspire me every day. Let us continue to hear from you.