Although nurses make up a significant proportion of the healthcare workforce, they are rarely represented on hospital boards. Now, some providers are pushing for more nurses to be included in boardrooms, arguing that they provide a crucial perspective on care quality and patient experience, Alex Kacik writes for Modern Healthcare.

Nurses are rarely represented on hospital boards

For decades, hospital and health system boards have largely been dominated by experts with backgrounds in banking, wealth management, and corporate investment rather than clinicians. In fact, a recent study found almost half of the board members of the 15 U.S. News & World Report top-ranked hospitals had finance backgrounds compared to less than 15% who had clinical experience.

Among clinicians, nurses are even more underrepresented than physicians. Among the board members in the study, only 0.9% were nurses — even though nurses make up more than a third of all healthcare jobs. Similarly, the American Hospital Association found that only 5% of hospital and health system board members were nurses in 2022.

According to experts, a lack of nurse representation in the boardroom may be due in part to biased selection processes, which often rely on referrals and lead to similar board compositions over time.

"It is a function of the perceived hierarchy within medicine and also gender issues," said Stephen Shortell, a health policy and management professor emeritus at University of California, Berkeley. "The process for recruiting board members has historically relied on board members reaching out to their own networks, so it is self-perpetuating."

However, it can also be difficult for hospitals to keep clinicians on the board in the long-term due to potential conflicts of interest, pressure from their peers, and the time commitment in addition to their other duties.

Jamie Orlikoff, president of Orlikoff & Associates, a firm that specializes in healthcare governance, noted that physicians and nurses who are directly employed by the hospital whose board they sit on are often required to sit out on discussions about compensation, medical licensure, and more.

"We would lose two to three clinicians every year because of conflicts," Orlikoff said. "You could have a great person, but then you can't use their input in the most important governance functions."

The benefits of having a nurse in the boardroom

According to Lori Boyd, an RN who has been on the board for Palo Pinto General Hospital for roughly a decade, boards without nurses are likely lacking a crucial perspective on care quality and the everyday patient experience.

"We have an extremely deep understanding of what [board] decisions mean in terms of a positive or negative outcome for the patient," Boyd said.

Amid rising labor costs and staffing constraints, there has been a greater push for boards to include nurses as members. Linda Aiken, a health policy professor at the University of Pennsylvania, noted that having more nurses on a board could increase nurse recruitment and retention.

With nurses' input on the board, hospitals could also improve their bottom lines by improving discharge planning to reduce readmissions, Aiken said.

Research has shown that there is a direct link between sufficient representation on a hospital board and workplace morale. In a study published in Nursing Outlook, Aiken and her colleagues found that over 70% of hospital bedside care nurses did not believe the top management would resolve problems identified in patient care.

"That is a glaring chasm that explains why nurses have no loyalty to their employers," Aiken said. "There is a reluctance to see nurses as a resource, not just a cost."

Other research has also suggested that having clinician input on a board can improve patient care and quality. For example, Sparrow Health System, which has two nurses and two physicians on its 15-person board, said clinician input has helped limit catheter-related infections, reduce patient mortality, and shorten the length of hospital stays.

"You are deficient as a governing committee if you lack clinical perspective," said Barbara Balik, an RN and former hospital CEO who chairs the quality committee on Presbyterian Healthcare Services' board. "I am confident that advocacy will continue to call attention to this issue and that representation will improve."

How to strike a better balance in the boardroom

If hospitals and health systems want to improve the balance of their boardrooms, they first need to improve their succession planning. According to a survey from the Governance Institute, only 44% of nonprofit hospitals have a current, written succession plan for their senior executive leadership.

"Succession planning in a large proportion of hospitals and systems is not good," said Lawrence Prybil, a former healthcare leadership professor at the University of Kentucky. "In today's world, hospitals need to constantly assess what talent we need around the table and what is lacking."

Having a comprehensive succession plan can reduce potential selection biases, Prybil said. For example, board members can use the plan to broaden the search for new members rather than relying on referrals from current board members alone.

According to Prybil, some other succession planning best practices include:

• Creating a committee
• Drafting and updating a list of qualified candidates
• Establishing term limits
• Regularly assessing any gaps in expertise

Overall, a mix of members with financial experience and clinical experience can be helpful to understand all challenges a hospital or health system might face, from lower investment income and rising interest rates to quality measures and patient care trends.

Hospitals are a business, Aiken said, "[b]ut within that business, that product is patient care. It seems obvious you would want to have experts of your product on the board." (Kacik, Modern Healthcare, accessed 3/22)