1. Hassmiller, Susan B. PhD, RN, FAAN


In this commentary, the author reflects on the results of the Robert Wood Johnson Foundation-funded survey, Opinion Leaders' Views on Nursing Leadership From Bedside to Boardroom: A National Survey Conducted by Gallup, and the article in this issue by Khourey et al, "Nursing Leadership From Bedside to Boardroom: A Gallup National Survey of Opinion Leaders."


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I have presented the results of the Robert Wood Johnson Foundation (RWJF)-supported Gallup survey, "Nursing Leadership From Bedside to Boardroom: Opinion Leaders' Perceptions" (, dozens of times to thousands of nurses throughout the country. Without fail, audiences are dismayed when I tell them that opinion leaders expect nurses to have the least influence of any stakeholder group on health reform in the next 5 to 10 years because we are not seen as major decision makers or revenue generators. They are incredulous that we are at the bottom of the list. But when I ask audiences how many of them serve on decision-making committees or boards, or have visited their state or federal legislators to educate them on healthcare issues, only a few hands are raised. Clearly, too few of us are at the table when policy decisions are made.


However, there is some good news among these findings: top healthcare opinion leaders overwhelmingly want nurses to be involved in decision making, particularly in the areas of reducing medical errors and improving patient safety, improving quality of care, promoting wellness and expanding preventive care. They believe that we could take on more leadership in improving health status and delivering services by making our voices heard and having higher expectations and accountability.


After hearing this, nursing audiences calm down and start thinking about the ways they already are involved in those kinds of decision-making roles at the patient's side and in the institutions they serve. We begin discussing what is required to go from bedside decision maker to boardroom leader. The healthcare knowledge and the nursing skills may be there now, but taking on leadership roles requires a new way of thinking and becoming involved in the healthcare of our communities, states, and nation. I am heartened that nurses are telling me that the Gallup results have galvanized them into making a new decision to broaden their horizons and find opportunities to lead.


There are many significant examples of nurses who have already taken on the mantle of leadership, resulting in higher-quality care, better patient experiences, and care that is more cost efficient. Here are just a few:



When Angela McBride, PhD, RN, FAAN was appointed in 2004 to the board of the 20-hospital and healthcare system of Indiana Health, the hospital had experienced some serious patient safety issues, including infant deaths due to improper medication administration. She suggested a wide range of changes to improve quality, making it a top board priority: instituting quality measures, requiring that new job descriptions include responsibility for quality and safety, mandating orientation on these priorities for new employees, and tying executive compensation to these attributes. The results have been dramatic: 6 hospitals have achieved Magnet(R) status, Riley's Children's Hospital has the best ICU data in the nation, and Indiana University Health is now listed in the "top 50" for a range of specialties.1


Improving Outcomes

Susan Lacey, PhD, RN, FAAN, director of the Bi-state Nursing Work Force Innovative Center, led an initiative of the Healthcare Foundation of Greater Kansas City and the REACH Foundation to provide staff training seminars at 7 regional hospitals focusing on improving patient outcomes, devising reforms, and putting them into place. The trainings and resulting innovations decreased the incidence of pressure ulcers, improved nurse job satisfaction, and saved an estimated $1 million in costs in 18 months.2



Mary Ann Christopher, MSN, RN, FAAN, president and chief executive officer of the Visiting Nurse Association of Central New Jersey, helped launch the telehealth program with Monmouth Medical Center for patients with congestive heart failure (CHF), diabetes, and chronic obstructive pulmonary disease. The goal was to use electronic and telecommunications technologies to support long-distance clinic-based healthcare in home settings. Monmouth has cut 30-day hospital readmission rates from 25% to 11%for CHF patients, and providers and patients report improved outcomes through enhanced patient self-care knowledge and compliance.3,4


Leadership Challenge

At the RWJF, we have long supported nurses as they have turned inspiration into action, creating models and programs that show how to do it better than it has been done before, and generally save money in the process. RWJF recognizes nurses as creative problem solvers. As the healthcare providers involved in almost every aspect of patient care delivery, members of the profession bring a unique skill set and perspective to the healthcare system. Nurses also enjoy enormous credibility with patients and their families and are consistently top ranked in another Gallup poll on professional honesty and ethics.5 But if we nurses want to be real agents of change in healthcare reform and policy, more of us need to step up to the challenges of leadership.


The recently released Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, underlines the importance of nursing leadership.6 Among the 4 major recommendations is a call for "nurses [to] be full partners, with physicians and other healthcare professionals, in redesigning healthcare in the United States."


The 2-part leadership recommendation first encourages nurses to "take responsibility for their personal and professional growth by continuing their education and seeking opportunities to develop and exercise their leadership skills" and, second, urges "public, private, and governmental healthcare decision makers at every level [to] include representation from nursing on boards, on executive management teams, and in other key leadership positions."6(p14)


It is clear that nurses must do more to prepare for and seek career paths to leadership. We need to join committees and boards, starting at the local or volunteer level, to develop our skills. We should seek out governance training to strengthen skills and understanding of board functioning and responsibilities. We must also identify opportunities to enter policy debates and, once in those discussions, communicate clearly and present data showing how nurses can contribute to improved care.


Nurses need to take on new leadership challenges-for example, developing an expertise in a specific area in which we are most passionate, whether geriatric, maternal, and early childhood, or an area of chronic disease such as diabetes. We must participate in patient care- and quality-focused research, publish our results, and then become an advocate for that work. When healthcare is on the agenda of our local city governments or state legislatures, we should visit our elected representatives-well prepared and armed with evidence-to present our points of view on how care should be shaped and funded.


Of equal importance, those of us with greater experience must become mentors and guides, encouraging newer nurses to develop expertise and leadership skills and offering suggestions on how best to climb the ladder of leadership, especially in how to gain a foothold on those first slippery rungs.


Decision-Making Involvement

But nurses cannot do it alone. Healthcare opinion leaders may say that they want us to be involved in healthcare decision making, but there is little evidence that they currently seek out and recruit nurses to serve in leadership roles. Nurses account for fewer than 2.3% of board seats in community health systems nationwide, whereas 23% of those positions were filled by physicians.7 It is time to do better. Hospitals and health systems serious about increasing quality and controlling cost should have nursing perspectives at the table when decisions are made about patient care and healthcare delivery.


Policy makers should also solicit the views of nurses and other healthcare practitioners, particularly as implementation of the Affordable Care Act begins. The goals of healthcare reform go beyond increasing coverage and access to healthcare; improving health and healthcare while bending the cost curve is another key priority. Effective system change will require all of us engaged in healthcare-from nurses and other providers to health system managers and policy makers-to be more collaborative, actively involved, and willing to let go of entrenched thinking and assumptions about professional roles.


With implementation of health reform now under way, right now is the right time to tackle the difficult and essential work of bringing nursing perspectives, knowledge, and voices into health policy decision making.



The author thanks Karen Waller and Jaimie Kelley for their thoughtful assistance on this article.




1. Hunt V. Overlooked Ingredient. Mod Healthc. 2009. Available at Accessed March 11, 2011. [Context Link]


2. Publications and Resources page. Robert Wood Johnson Foundation Web site. Available at Accessed March 11, 2011. [Context Link]


3. Resources. Future of Nursing Initiative Web site. Available at Accessed March 11, 2011. [Context Link]


4. Federal Funding Secured to Expand Successful Telehealth Program. Visiting Nurse Association of Central Jersey. House Calls Publication. Vol 20. No. 1. Available at Accessed March 14, 2011. [Context Link]


5. Jones J. Nurses Top Honesty and Ethics List for 11th Year. December 3, 2010. USA Today/Gallup Poll. Available at Accessed March 14, 2011. [Context Link]


6. Committee on the Robert Wood Johnson Foundation Initiative at the Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011. [Context Link]


7. Prybil LD. Engaging nurses in governing hospital and health systems. J Nurse Care Qual. 2009;24(1):5-9. [Context Link]