Terry McDonnell, DNP, RN, ACNP-BC, is Chief Nurse Executive and Senior Vice President at Duke University Health System and Vice Dean for Clinical Affairs at Duke University School of Nursing. With 25 years of enterprise healthcare leadership across organizations from $50M to enterprise scale, she has led transformational initiatives in workforce equity, AI-powered care delivery, and nursing innovation. A Gold Stevie Award winner for Most Resilient Female Leader and a Modern Healthcare Leading Women honoree, she is a Forbes contributor, global keynote speaker, and practicing Acute Care Nurse Practitioner in GI Oncology.
Recently, in an exclusive interview with CIO Magazine, Terry shared insights into leading at the intersection of clinical expertise and executive strategy. Addressing the national nursing crisis, she argues that workforce sustainability is an operating model problem, not an HR problem, and points to Duke’s Co-Care Model pairing bedside nurses with virtual nurses and AI-supported tools as proof that redesigning care delivery cuts burnout and turnover far more than perks ever could. On health equity, she says technology alone will not close gaps unless representation becomes an operational imperative, because systems designed by people who have navigated barriers make different, better decisions for communities. For early-career nurses, her advice is direct: raise your hand, volunteer for strategy-adjacent committees, understand the budget, read the annual report, propose solutions, and become a visible thought leader, because influence is earned long before permission is granted. The following excerpts are taken from the interview.
You stand at the intersection of clinical expertise and executive strategy. What moment at the bedside first made you realize you wanted to influence healthcare from the boardroom, not just the floor?
It was not a single moment, rather it was a series of moments, accumulated over time spent at the bedside and in the clinic, with colleagues that shared the continued frustration that the work they were doing was not reflected in the decisions being made about them. They wanted their reality to be represented in leadership. They wanted the people setting strategy to understand what it meant to care for a patient at two in the morning, or to navigate a family in crisis, or to manage a shift that was already short-staffed before it started.
That is why I have maintained my clinical practice throughout my executive career. I see patients in GI Oncology not as a formality but because it is the most important accountability mechanism I have and ultimately it is our why… It keeps the distance between the boardroom and the bedside from growing too wide. Every workforce decision I make, every technology I implement, and every transformation initiative I lead, I must be able to defend in the room where the care happens. That obligation never goes away. It just gets more consequential as the scale of the work grows.
Nurse turnover and burnout remain national crises. What structural shift — not just perks — will actually stabilize the nursing workforce by 2030?
We need to stop treating workforce sustainability as a human resources problem and start treating it as an operating model problem. Perks, bonuses, wellness apps, and free meals, are generous gestures that do not address structural reality. Nurses are leaving the bedside because the conditions of the work have become unsustainable. It is a design failure, not a motivation failure.
The shift that will move the needle is redesigning how care is delivered so that nurses are not simultaneously managing the cognitive load of multiple competing tasks while also being asked to be fully present for the complex human beings in front of them. At Duke, we are addressing this directly through our Co-Care Model, which pairs bedside nurses with virtual nurses and AI-supported tools that redistribute the documentation burden, the administrative coordination, and the safety monitoring, so that the nurse at the bedside can focus on direct patient care. This new model reduces burnout significantly and we have seen a reduction in turnover.
By 2030, the organizations that stabilize their workforces will be the ones that redesigned care delivery — not the ones that offered the most competitive sign-on package.
Health equity is a stated priority, but gaps persist. Which operational change will do more to close disparities than any new technology?
Representation at every level of decision-making as an operational imperative. The gaps that persist in health equity are not primarily the result of insufficient data or inadequate technology. They are the result of systems designed by people who didn’t have to navigate the systems. When the people designing care delivery have personally experienced what it means to navigate barriers to access, or have family members and colleagues who have, different decisions get made.
The operational change I would prioritize is ensuring that the clinical and administrative workforce at every level, from the unit to the boardroom, reflects the communities being served. The institutional knowledge that comes from lived experience changes the questions being asked. It changes how work and problem solving are prioritized and changes the patient experience.
Technology can accelerate progress once the direction is set and the strategic priorities reflect the priorities and needs of the people we serve within the community.
Leaders who carry both clinical and executive weight need grounding. What book, philosophy, or person outside healthcare has most shaped how you lead?
Robert Fulghum’s All I Really Need to Know I Learned in Kindergarten. I have come back to that book more times than I can count — not because it is simple, but because it is ruthlessly true. Share everything. Play fair. Don’t hit people. Clean up your own mess. Say sorry when you hurt someone. Warm cookies and cold milk are good for you. Live a balanced life.
These simple truths create the perfect operating philosophy for leading large, complex organizations through hard change. The most expensive failures I have witnessed in healthcare leadership: the mergers that destroyed culture, the technology implementations that disrupted, and the workforce crises that were allowed to fester could be traced back to a violation of principles of community and simplicity.
I keep Fulghum close because executive leadership can accumulate a kind of institutional sophistication that makes simple ethical clarity harder to see. The titles, the budgets, and the complexity can make obvious things feel complicated. When that happens, I find it useful to go back to the beginning and keep things simple.
You’re a relentless advocate for workforce development. What’s the one skill you believe every nurse leader must develop to survive the next decade?
Financial fluency. The ability to translate clinical value into financial language is what determines whether a nursing leader has influence over the decisions that shape the work. The leaders who will have the greatest impact on nursing in the next decade are the ones who can walk into a room with a CFO or a board and make the case for a workforce investment with a clear ROI.
I have watched extraordinary clinical leaders fail because they made an impactful decision that wasn’t vetted for financial risk. The turnover cost per nurse. The revenue impact of a ten-day reduction in average length of stay. The liability exposure of a preventable harm. These are the metrics that move decisions. And nurse leaders who can speak that language without abandoning clinical values will shape the future of the profession in ways that pure clinical advocacy cannot.
The leaders who will be highly successful will balance their clinical skills with financial and strategic acumen.
From frontline nurse to SVP shaping billion-dollar strategy, what core belief about healthcare has stayed constant for you, no matter the size of the budget or team?
Never before has the imperative for change been stronger and I think we can all agree that what got us here will not move us forward. That conviction has been with me from the beginning, and it only sharpens as the work becomes more challenging.
Academic healthcare has extraordinary strengths in the clinicians, and the science, balanced with genuinely compassionate care. But it also carries institutional inertia that protects models and structures long past the point where they serve patients or the people delivering care.
The belief that has anchored everything for me is that our staff and our patients need to be reflected in our leadership and in the decisions we make. We can’t ever forget that the people best equipped to solve for the problems of today are those closest to the work. When we engage our staff to identify and solve problems, better decisions are made.
For early-career nurses with leadership ambitions, what’s the first move they should make if they want a seat at the strategy table?
Raise your hand first and volunteer to participate in solving problems. Bring your voice to quality committees, finance committees, governance structures, and workforce councils. Volunteer for the work that is adjacent to strategy, not just the work that is central to your current role. Every institution has committees that need members, and projects that need clinical perspective.
Understand the budget and how budgeting works. Understand the strategy and read the annual report. Be the person who comes with problems and propose solutions.
Be visible beyond your unit. Be a thought leader and share your insights externally at conferences and in broader forums. Every article, every conference panel, every LinkedIn post that reflects your genuine thinking expands the sphere in which you can have impact. The nurses who will lead healthcare through the next decade are already doing this work, they are not waiting for permission, neither should you.