HEALTH CARE in America truly is in the midst of transformational change. An aging and increasingly diverse population, dramatic advances in medical science and technology, growing public interest in health and medical care prompted in part by the Patient Protection and Affordable Care Act and the availability of health insurance it has provided for millions of additional citizens, the rising voices of more informed and demanding consumers, the ongoing shift from fee-for-service to value-based payment systems, and a growing focus on population health are among the powerful forces that are altering the health care landscape. In addition, the basic structure of our nation's health enterprise is changing dramatically through the consolidation of previously independent hospitals into health systems, rapid integration of physicians into these systems through employment and other forms of affiliation, development of a broad array of ambulatory care and telemedicine models, and mergers of health insurance companies into a shrinking number of massive entities.

All of these changes affect the role and responsibilities of hospital and health system boards. The issues they must address are more complex and key stakeholders-including the Internal Revenue Service and other government regulators, public and private payers, bond rating agencies, the media, and the public-at-large-are demanding more transparency, accountability, and better performance by hospital and health system boards.1,2 These increasing expectations are fueled by a growing body of evidence that board composition, practices, and effectiveness have material impact on the performance of the organizations they govern.3-5

Given these developments and growing evidence regarding the importance of nursing care and nursing leadership in determining the quality and cost of patient services, it would seem evident that the presence of nurse leaders on the boards of health care organizations would increase. The value of including the expertise and perspectives of nurses in board deliberations has been examined in recent years.6-9 In addition, nurses continue to comprise more than half of the workforce in most hospitals and other large health care organizations and are ranked by the American people as our nation's most honest and ethical occupational group, a view the public has held consistently for decades.10

So, to what extent have the nursing profession's size, impact, and the public's enduring respect been reflected in the presence of nurse leaders as voting members of the governing boards of health care organizations? While incomplete and somewhat inconsistent in definitions and data collection methodologies, information about nurse involvement on boards has been available for 10 years. This information together with comparable data for physicians is summarized in the Table. These data from 8 independent studies of hospitals, health systems, and academic medical centers over the past decade show the proportion of nurses as voting board members among the organizations that were examined has ranged from 2% to 6%.4,11-17

Table. Nurse and Physician Composition on Health Care Organization Boards

Despite a well-documented case that the expertise, experience, and perspectives of nurse leaders can add value to board deliberations, the findings from this series of studies do not indicate that nurse engagement as voting members of health care organization boards is increasing. In fact, their involvement in governance continues to be modest and uneven. For example, a recent study of academic medical center governance found that 69% of the respondents had no nurses as voting members.4 Similarly, a 2013 study of hospitals in New York City showed that 74% of their boards did not include any nurses.18

DISCUSSION

For many years, several leading health-related organizations including the Institute of Medicine, the National Quality Forum, and the Robert Wood Johnson Foundation have been advocates for involving nurses as well as physicians on the boards of hospitals and other health care organizations. In 2007, for example, the American Hospital Association Blue Ribbon Panel on Health Care Governance recommended that boards "include physicians, nurses, and other clinicians on the board. Their clinical competence and viewpoints are valuable to other board members and will help the board better understand the needs and concerns of several of the organization's stakeholders."19^(p13) However, despite the powerful case for engaging nurses in governance roles and the advocacy efforts that have been made by numerous organizations and health care leaders, the actual presence of nurses as voting members of health care organization boards continues to be limited. Factors that have contributed to this situation have been identified and, unfortunately, continue to linger.7,15 In brief, it appears that key factors include the following:

* Gender disparities. About 90% of registered nurses (RNs) in the United States are women, and gender disparities continue to exist in the board composition of large organizations in virtually all sectors of American society. For example, in 2012, only 17% of Fortune 500 board members were women and only 3% of these boards were chaired by women.20 The gender mix is somewhat more balanced in the hospital and health system sector where, in 2014, 28% of board members were women.17 However, the limited presence of nurses as voting board members in hospitals, health systems, and academic medical centers can be viewed to some extent as a reflection of persistent gender disparities in all sectors.

* Uneven understanding and appreciation of the nursing profession. The composition of the nursing profession is both complex and is evolving. It includes licensed practical nurses, many of whom do not have college degrees, RNs with associate degrees and others with baccalaureate degrees, and an increasing number who have earned graduate degrees. To lay board members who typically populate the committees charged with assessing their board's needs for new talent and nominating candidates for board appointments, this diversity can be difficult to grasp and understand. Oftentimes, lay board members simply view nurses on the whole as mid-level technicians and fail to appreciate that a growing proportion of nurses are highly educated and skilled professionals with expertise and experience that would be of great value to board deliberations.

* Board policies on eligibility for board appointments. Many hospitals and health systems have formal or informal policies that restrict organizational employees other than the chief executive officer (CEO) from serving as voting members of their governing board. Even if the board committee with responsibility for identifying and nominating candidates for board appointments recognizes the potential value of engaging nurse leaders in board deliberations, this policy can unnecessarily block the nomination of nurses for board appointments. Boards can and should consider highly qualified nurses who hold leadership positions in organizations other than their own as candidates for board appointments, for example, nurse leaders in other hospitals and health systems and university faculty members. There is a large and growing pool of highly educated nurses whose experience and skills would enrich board deliberations, many of whom, if asked, would be pleased to consider a board appointment in a health care organization where they are not employed.

It is clear that, throughout the country, a combination of these and other factors have limited the appointment of nurse leaders as voting members of hospital, health system, and academic medical center boards. The result is that, in a majority of these institutions, nurse leaders are present in board meetings as observers rather than full participants and, in too many cases, are totally absent from board and board committee meetings. The result is these boards do not benefit fully from the rich experience, input, and insights that highly qualified and dedicated nurse leaders can bring to governance deliberations and decision making.

So, what can be done to change the current picture and increase the engagement of nurses in governance? Some steps that I believe are feasible, have potential impact, and should be taken include the following:

* First, board leaders and CEOs of health care organizations where nurse leaders have been appointed as voting board members and have witnessed at firsthand their impact on board deliberations should be encouraged to share this experience with their counterparts in other organizations who have not yet added nurses to their boards. Their experience should be shared in many ways, for example, in informal dialogue with colleagues, in presentations at educational conferences, or in publications such as some already have done.21 Board leaders tend to respect and listen to the views of other board leaders, and CEOs typically pay attention to what other CEOs have to say. It is important to remember that a large proportion (about two-thirds) of hospitals, health systems, and academic medical centers do not have nurses on their boards, so most board members and CEOs have not had personal experience in working with nurse leaders in the role of voting board members.

* Second, at the national and state levels, the leaders of hospital and nursing associations who share a common interest in improving governance in health care organizations should initiate dialogue about the idea of taking deliberate actions to promote the appointment of more highly qualified nurse leaders to the boards of health care organizations. In many communities around the country, it has become increasingly difficult to identify highly talented and skillful persons who have the competencies needed to be excellent board members and are willing to dedicate the time and effort governance roles presently demand.22 The nursing profession includes a large and increasing number of well-educated and highly talented leaders who have the capability to make significant contributions to board deliberations. Joint advocacy efforts by leading hospital and nursing associations could be very effective in encouraging hospital and health system leaders to carefully consider recruiting outstanding nurse leaders to serve on their governing boards.

* Third, there is great need and opportunity for formal studies regarding the impact of including nurse leaders as voting members of health care organization boards. As only one illustration, the views of board members and CEOs of hospitals and health systems who have added nurses as voting members could be obtained systematically, analyzed, and reported to the field. Some research is being done on the impact of adding women to boards and executive teams in other sectors, and early results are finding positive impact on performance.23 To date, however, there has been minimal research about the impact of engaging nurses as board members in health care organizations and, for several reasons, objective studies in this realm would be timely and valuable.

* Fourth, to augment their experience in patient care and nursing leadership roles, nurses who aspire to board roles would benefit from education about governance in the contemporary health care environment, for example, the fiduciary duties, responsibilities, and authority of boards in various organizational models; the core characteristics of effective governance; and case studies about boards that work exceptionally well and others that have made mistakes that should be avoided. Educational programs of this nature could be developed and provided in several ways. For example, in universities that have both a nursing program and a graduate program in health management and policy, there is a natural opportunity for collaboration in designing and offering educational programs about health care governance for interested nurses.

To govern effectively in an environment that is in the midst of transformational change, the boards of all health care organizations must include a multidisciplinary blend of highly capable persons, all of whom share dedication to the organization's mission and commitment to improving its performance. It is my belief that board deliberations are enriched significantly by the presence and contributions of highly qualified nurse leaders, and it is my hope that their presence around boardroom tables will increase markedly in the coming years.

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