There are 3.5 million registered nurses in the United States, and they comprise a large proportion of most hospital staffs and budgets.

And yet, just 2 percent of hospital trustees are nurses, according to research from a 2009 study of governance in nonprofit hospitals. By contrast, the study showed that about 20 percent of trustees are physicians.

"That's ridiculous," says Connie Curran, R.N., a hospital governance consultant who urges her board clients to seek out nurses as members. She says they provide a crucial patient care perspective, particularly on issues such as quality and patient safety. "The only group of professionals who are in a hospital 24 hours a day are the nurses, so they bring a unique perspective and expertise, and knowledge that is very valuable," Curran notes.

Curran herself has served on three different community hospital boards and recalls a number of situations in which her knowledge of hospital operations helped the board. In one instance, the board was considering shutting the hospital pharmacy overnight on weekends to save money. "I said, 'Wait a minute, who's going to get the medications for the patients and the ER?' They just didn't understand how hospitals operate."

There are many good reasons to put people with nursing backgrounds on hospital boards, argues Les MacLeod, a professor of health management and policy at the University of New Hampshire in Durham, who is serving as interim chief executive officer of Huggins Hospital in Wolfeboro, N.H. "Nurses play such an essential role in all aspects of the organization," he says.

In a 2010 article in Nurse Leader magazine, he listed many reasons for having a nurse on the board. Among them:

  • Patient satisfaction: Nurse leaders are familiar with the often-subtle interconnectedness of the many services that impact patient satisfaction and can help to avoid unintended consequences of board decisions.
  • Medical staff relationships: Effective teamwork and cross-professional collaboration ... at the nurse-physician level, are essential to good patient care; this can be furthered by having nurse leaders at the governance table alongside their physician counterparts.
  • Quality of care: Including a nurse leader on the board is imperative to improving quality and safety measures.
  • Financial considerations: Nurses know where expenses can be reduced as well as where they cannot; a commitment to nursing-finance collaboration needs to start at the top.
  • Board education: A nurse leader's governance role can help set the stage for a much-needed educational exchange of ideas and perspectives.

Getting more nurses on hospital boards has been advocated by the Institute of Medicine in its 2011 report, "The Future of Nursing" by the Robert Wood Johnson Foundation's Nurse Leaders in the Boardroom project, and by hospital quality guru Donald Berwick, M.D., who wrote a few years ago that "the performance of the organization depends as much on the well-being, engagement and capabilities of nursing and nursing leaders as it does on physicians."

The traditional board makeup has leaned heavily on trustees with financial backgrounds, such as bankers and business executives. But that focus on the balance sheet and developing new lines of business has needed adjustment over the past decade as payers such as Medicare and many large insurers begin to demand quality-of-care information and improvement. Nurses, who spearhead many quality improvement initiatives, also are tied intrinsically to both staff and patient satisfaction.

Conflicts of Interest?

Because nurses are hospital employees, there may be concern about a potential conflict of interest in their voting on budget matters. In fact, a nurse who won a seat on the public district hospital board for Skagit Valley Hospital in Mount Vernon, Wash., had to step down in January because a state law prohibits public district hospital employees from serving on their boards, according to a report in the Skagit Valley Herald.

But advocates of nurses on boards argue that there are many ways to avoid conflicts of interest. For one, nurses can be recruited to the board from outside the hospital.

Also, the board can deal with potential conflicts of interest from a nurse trustee in the same way as it does with any other member, such as a physician with a financial relationship with the hospital or a banker whose institution is lending money for a hospital construction project, Curran says. "I don't think a nurse has any more conflicts of interest than anyone from the community," she says.

Hospital boards already should be asking trustees routinely whether there are conflicts before they take up specific issues, she notes, and allowing members with conflicts to bow out of those conversations.

Curran says she is surprised by how many boards don't know where to recruit nurse trustees. "Nurses are everywhere," she says. "Within five miles of you there's a community college with a nursing school and a dean who could serve. Look at four-year schools, the Red Cross, the American Heart Association, the public health department."

At the same time, she says, nurses need to ready themselves for leadership positions on boards. Curran is a trustee for a hospital board that introduces board service to potential recruits by placing them as a community member on a committee, such as quality. If, after a year or so of working on the panel works out to the mutual satisfaction of the board and the recruit, they ask the person to join as a trustee. That kind of training ground could be ideal for a nurse who wants to move into governance.

MacLeod also argues for choosing the right nurse trustee, rather than simply filling a spot on the board with a nurse who isn't prepared. Just like any trustee, he says, "they have to earn a place in the boardroom."

Jan Greene is a freelance writer in Alameda, Calif.

For more on governance and the nurse perspective, please see "A New Voice at the Table," March 2012.