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The Promise of Nursing Leadership

Nurses are the nation’s most trusted profession. Why don’t they have more  leadership roles?

For 15 consecutive years, the Gallup survey organization has rated nursing the most trusted profession in the U.S. Yet nurses are continuously underrepresented in organizations that make large-scale health care decisions. Just 37 percent of hospitals have a nurse on their governing boards, while 75 percent include a physician. The same skills that are crucial to the successful functioning of a health care board—health care delivery, quality, and responsiveness—are central to the work that nurses do.

But while nurses often work the closest with patients and communities served by hospitals, current literature shows that other health care leaders do not consider them influential.

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 high-performing hospitals’ boards included at least one nurse as a voting member, versus only 11 percent of low-performing hospitals. Another found that Chief Nursing Officers were more familiar with landmark reports on quality and safety than were board chairs. The same study noted that board chairs tend to have more limited knowledge of salient nursing quality issues such as nurse-patient ratios and staffing, work environment concerns, and reduction of adverse events such as pressure ulcers and falls.

Thought leaders seem to support an increased leadership role for nurses. A 2009 Gallup Poll of 1,500 university faculty, corporate executives, health services leaders, and government officials found agreement that nurses should have more influence in improving care quality and population wellness.

The landmark 2011 Institute of Medicine Report, The Future of Nursing: Leading Change, Advancing Health addresses this issue. Recommendation seven of the report calls for the nation to “Prepare and enable nurses to lead change to advance health,” and it urges nurses to actively seek skills and opportunities for board placement. In response to that study, 29 organizations formed the Nurses on Boards Coalition (NOBC) 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.

Nonetheless, numerous barriers to nurse leadership persist. 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 as leaders responsible for high-level clinical and organizational decision-making. A third discussed how hospital, health system, and other organizational boards fail to recognize the need for a nurse on board, especially if they already have a physician.

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 nonprofit. While nurses provide excellent value to hospital leadership, organizational boards of all sorts 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.” We know that nurse leaders possess a unique set of skills—including finance, communication, process improvement, strategic planning, and patient services— that any organizational board will value. It’s time to use nurse leaders to improve quality patient care.

Jacqueline Nikpour 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. A version of this essay originally appeared in Health Policy Sense, a blog of Penn’s Leonard Davis Institute of Health Economics.