Dr. Naylor Featured in Modern Healthcare... a look at nurses' role in policy and decision-making

A different nursing shortage

While nurses govern patient floors at not-for-profit hospitals, few do the same on boards—but that’s beginning to change


By Melanie Evans

Posted: April 13, 2009 - 5:59 am EDT



Healthcare’s single largest occupation is making gains in U.S. hospital boardrooms as directors and trustees grapple with efforts to curb costly and harmful medical errors.

On healthcare governing boards, nurses remain in the minority among experts in finance, business and law—more often recruited to oversee strategy and performance at the nation’s not-for-profit hospitals, according to nursing and governance experts. That appears to be changing, albeit slowly, as hospital board oversight extends beyond finance and executive payouts to healthcare quality and safety.

Nurses handle the everyday work of caring for hospital patients, an around-the-clock job that often also means tending to anxious families and one that gives nurses a working knowledge of healthcare delivery, proponents of more nurses in the boardroom say. That experience leaves them particularly suited to address questions of access, delivery and quality with an eye for what works or what doesn’t, they say.

Aurora Health Care, based in Milwaukee, added a University of Minnesota nursing professor to its board in September after the departure of the system’s prior nurse director, a move the system’s top executive says underscores nurses’ importance to healthcare quality and safety.

“Why would any board not have a nurse on the board?” says Nick Turkal, Aurora’s president and CEO. “I think it’s common sense, when you look at where healthcare is delivered.”

The system, which owns 12 Wisconsin hospitals, recently began working with the University of Wisconsin and a major healthcare technology company to add nurse-specific queries to its electronic health records to improve outcomes linked to nursing performance. “We have a nurse on the board because we clearly understand the huge importance of nursing,” Turkal says.

But governance experts have stopped short of calling for a mandate for nurses to sit on hospital boards. The Center for Healthcare Governance, an affiliate of the American Hospital Association, in 2008 recommended that boards include clinical experts, such as doctors, nurses or other healthcare providers, but did not single out any one professional as essential. The report further cautioned that boards should carefully screen out those primarily interested in advancing their profession’s interests rather than the hospitals’ needs.

Directors and trustees need advice on quality and safety but should recruit the most qualified experts, regardless of training, says Sarah Eames, a search consultant with Russell Reynolds Associates and a director for Novi, Mich.-based Trinity Health, which owns 28 hospitals and manages another 14. “Frankly, it’s not necessarily a nurse,” she says.

Perspective, not parity

Nursing and governance experts say few hospitals and health systems have nurse directors or trustees, but the number is gradually on the rise. By one measure—hospital executives with some sway over governance—nurses are in the extreme minority. In two polls conducted two years apart (2005 and 2007) by the Governance Institute, fewer than 1% of hospitals and systems reported that chief nursing officers voted on their governing boards.

“It’s small, but it’s growing,” says Joanne Disch, a clinical professor and director of the Katharine J. Densford International Center for Nursing Leadership at the University of Minnesota School of Nursing.

Disch joined the board of a second health system—Aurora Health Care—last September, and has served for nine years as a director for Allina Hospitals & Clinics in Minneapolis, which owns 11 hospitals and manages one.

Disch admits that she is a proponent of greater nurse representation on hospital boards and says her enthusiasm has nothing to do with whether physicians hold more board seats. Among the more than 700 respondents to the Governance Institute’s 2007 survey, boards had an average of two physicians.

“It’s not a parity thing; it’s a perspective thing,” Disch says.

Nurses understand from experience how to effectively address two critical goals facing any hospital board: Improve quality and reduce costs, she says. “A nurse would understand where it’s safe” to curb costs without compromising quality, says Disch, a perspective that’s critical as boards weigh strategy and budget options.

One major health philanthropy, the Robert Wood Johnson Foundation, launched a campaign in 2007 to put at least a dozen nurses on influential healthcare quality or journal boards by 2009 and is exploring a governance certification tailored for nurses. Susan Hassmiller, a nurse who oversees the foundation’s effort as senior adviser, described the push as an effort to increase the profession’s influence on health policy and quality improvement. The program has formally placed at least seven nurses on boards to date but an informal network has also helped secure nursing positions on influential committees and boards.

“The point is that it takes a multiprong strategy,” Hassmiller says in an e-mail. “I hope that at the very least our program is heightening the awareness of the unique characteristics and value that nurses bring.”

The foundation hired search firm Isaacson, Miller to cultivate potential nurse trustee candidates. A 2007 survey of 30 major healthcare groups—including the American Hospital Association and the Joint Commission—health systems and industry journals found

30 of the 488, or 6.1%, were nurses. Among the initiatives’ advisers are prominent doctors, nurses and recognized industry leaders, including Henry Ford Health System’s president emeritus Gail Warden.

Warden says research that increasingly links nurses to healthcare quality and safety has bolstered the case for their importance to hospital governance. He says that the nation’s shortage of nurses and a growing awareness of nurses’ extensive work with patients and their families have also raised awareness of the profession’s importance.

“I’ve always felt strongly that people don’t understand the fact that the nurse and nursing … is the part of the organization that is responsible for the care of the patient” around the clock, he says.

Mary Naylor, one of the initiative’s recruits, joined Warden on the health advisory board for RAND Corp., a public policy think tank. Naylor, a nurse and director of the University of Pennsylvania School of Nursing’s NewCourtland Center for Transitions and Health, says nursing has long focused on prevention and patient-centered care, which means nurses understand healthcare delivery as patients do, a valuable asset in the battle against chronic disease.

Knowledge, not degree

Pamela Knecht, president of Chicago consulting firm Accord Limited and an adviser to the Governance Institute, says she has seen a “little bit of a trend” of nurses joining hospital governing boards, a shift she credits to the heightened focus on patient safety and clinical quality.

The past decade has brought heightened scrutiny from regulators, politicians and consumer watchdogs of how aggressively hospital boards oversee their organizations’ operations.

Corporate scandals earlier in the decade led Congress to respond with the Sarbanes-Oxley Act of 2002, a sweeping law to bolster corporate accountability. The rules did not apply to not-for-profit hospitals and health systems, but put pressure on boards even as the sector faced inquiries of its own. Demand for greater access to care and improved quality have prompted calls from policymakers and regulators for hospital boards to be more accountable, transparent and assertive (March 2, p. 6).

That attention had raised interest in how boards govern—and who sits on them—from outside and within the industry. The Internal Revenue Service overhauled disclosure rules beginning with 2008 tax records for not-for-profits and included more detailed questions on governance policies and board makeup. Meanwhile, good governance efforts within healthcare have increasingly pushed boards to look closely at trustees’ relationships, personal and professional, and at the skills and experience board members can bring to oversight.

Last year, the Center for Healthcare Governance released the first of two reports on the best practices and necessary expertise for hospital boards. The initial report outlined the composition and size of boards with the most effective cultures and stressed the need for diversity and clinical expertise, and said that clinicians, such as nurses and doctors, should be included on the boards. The second report, issued in February, focused on the skills, education and attributes needed in board members.

John Combes, the center’s president and chief operating officer, says it’s important to get nurses involved in governance and that more boards have done so. “Hospitals are basically just large nursing units,” he says. “Without nurses, hospitals wouldn’t exist.”

Combes says he sees a growing number of nurses on governing boards and credits the shift to hospital boards’ increasing responsibilities. “It’s not just about business and finance,” he says. Boards need directors or trustees who understand healthcare delivery and can help improve its quality and responsiveness. More hospital and health systems reported their boards included a quality committee in 2007, 62%, vs. 56% two years earlier, the Governance Institute surveys show.

He rejects the idea that boards must include nurses or any other profession, but says instead a board’s makeup should be balanced with skills, background and knowledge to address the issues facing hospitals and to give voices to those who have something at stake.

Accord’s Knecht says hospitals and systems recruit nurses out of retirement, from college faculty or nonrival healthcare businesses, but need to avoid their own employees to steer clear of conflicts of interest. She describes the potential pool of candidates as “not as big as one would like,” particularly for more isolated, rural hospitals without nearby schools to draw from.

Nurses may face pressure to put the profession’s interests ahead of the hospital’s needs, Knecht says. As trustees, nurses must also be able to think strategically or risk falling into the trap of trying to manage hospital operations rather than govern. “It can be hard to find the right kind of person,” she says.

Disch of the University of Minnesota rejected the idea that nurses may be more susceptible to overstepping the role of trustee and director. “Anyone on the board can get into the weeds,” she says.

Knecht says nurses don’t have to sit on the board to contribute to governance. Trustees should review nurse satisfaction and clinical quality data. Nurses can attend board meetings or contribute by sitting on committees, and indeed CNOs should do both, she says. The Governance Institute surveys found that the percentage of nursing chiefs who were not board members but who attended board meetings inched slightly upward to 83% in 2007 from 79% two years prior.

Hospital governing boards should include someone with clinical experience, but that does not mean it must be a nurse, Knecht says. Doctors, physician assistants or nurses can bring such necessary expertise to the board. A nursing background is “desirable, but not required,” she says.