Health Policy$ense

The Promise of Nursing Leadership

Nurses are the most trusted profession in the U.S, but are continuously underrepresented in leadership roles.

For 15 consecutive years, nursing has been rated as the most trusted profession in the U.S. Yet, nurses are continuously underrepresented in organizations that make large-scale health care decisions. Merely 37 percent of hospitals have a nurse on their governing board, compared with 75 percent that include a physician. Skills in health care delivery, quality, and responsiveness to the public are seen as crucial to the functioning of a health care board, and are nothing short of central to the work that nurses do. But although nurses often work the closest with patients and communities served by hospitals, current literature shows they are not seen as influential decision makers by other health care leaders.

A growing base of research points to the value of nursing leadership. A 2015 study in the American Journal of Medical Quality (AJMQ) found that 44 percent of boards of high-performing hospitals included at least one nurse as a voting member, versus only 11 percent of low-performing hospitals. Another found that Chief Nursing Officers (CNOs) were more familiar with landmark reports on quality and safety than board chairs, and noted board chairs have more limited knowledge of salient nursing quality issues. These issues include nurse-patient ratios and staffing, work environment concerns, and reduction of adverse events such as pressure ulcers and falls. And while nurses may not be seen as current influential decision-makers, a 2009 Gallup Poll of 1,500 opinion leaders (university faculty, corporate executives, health services leaders and government) found agreement that nurses should have more influence in improving care quality and population wellness.

Although nurses often work the closest with patients and communities served by hospitals, current literature shows they are not seen as influential decision makers.

The landmark 2011 Institute of Medicine Report, The Future of Nursing: Leading Change, Advancing Health also addresses this issue. Recommendation 7 of the report states “Prepare and enable nurses to lead change to advance health,” and urges nurses to actively seek skills and opportunities for board placement. As a result, the Nurses on Boards Coalition (NOBC) was established with a grant from the Robert Wood Johnson Foundation. NOBC now works to advocate for nurse leadership, assist nurses with skill development important for board service, and foster a network of nurses who serve and who wish to serve on boards. Numerous education resources, such as Board Core Competencies and Best On Board can be found on the organization’s website for nurses who are interested in pursuing board service to learn more.

Beyond skill-building, numerous barriers to nurse leadership still exist. One study noted that, as a female-dominated profession, nurses must prove themselves worthier than their male counterparts. Another found that nurses are often seen as “doers”, or mid-level technicians, rather than leaders responsible for high-level clinical and organizational decision-making. A third discussed how hospital, health system, and other organizational boards don’t recognize the need for a nurse on board, especially if they already have a physician. But perhaps most importantly, more research must be done to connect executive nursing leadership with quality, cost-efficient outcomes for patients. While many surveys and other qualitative studies point to the need for nursing leadership, the AJMQ study is the only quantitative trial conducted to find an association between patient outcomes and nursing leadership. Narrowing this knowledge gap will be essential in the push to advance nursing leadership and the profession as a whole.

Nurse leaders and other stakeholders can take several steps to foster board placement. Nurses can talk to employers and co-workers about the benefits of having a nurse on board, and encourage them to invite a nurse leader to serve. Non-nurses who serve on boards can reach out to their nurse leader colleagues to discuss possibilities for board service. Lastly, nurse leaders can seek mentorship and leadership experience, such as by volunteering with a favorite local nonprofit. While nurses provide excellent value to hospital leadership, all organizational boards can benefit from the unique knowledge and skills of nurses.

As the current health care system continues to evolve, so must health care leadership. The Future of Nursing report calls on “all members of the health care team... [to] share in the collaborative management of their practice. Physicians, nurses, and other health professionals must work together to break down…hierarchal silos and hold each other accountable for improving quality and decreasing preventable adverse events”. We know that nurse leaders possess a unique set of skills including finance, communication, process improvement, strategic planning, and patient services, which are valuable to any organizational board. It’s time to use nurse leaders to improve quality patient care. 

Jacqueline Nikpour, BSN, RN, is a 2017 graduate of Penn's School of Nursing.  She received the Mary D. Naylor Undergraduate Research Award for her contributions to advancing nursing knowledge through research.