NURSES comprise a large proportion of the hospital workforce, and the centrality of nursing in determining the overall quality of patient care is unarguable. Hospitals and their patients depend on nurses around the clock every day.

Landmark reports by the Institute of Medicine in 19991 and 20012, by the Commonwealth Fund in 20043, and by other groups have identified serious quality issues in our nation's hospitals. The National Quality Forum, the Institute for Healthcare Improvement, and other prominent healthcare organizations have urged hospital boards to reach out and engage clinical leaders in developing goals and strategies for improving the quality of patient care.

Improving communications with clinicians-physicians and nurses-and strengthening their level of engagement in quality improvement initiatives can take many forms. One approach is to engage clinicians by involving them on governing boards and board committees. Hospital boards establish institutional goals, set institutional policies, and have legal and moral responsibility for the quality of care provided in their institutions. Inviting and hearing the voices of physicians and nurses in governance deliberations and decision making would seem intuitively to be both appropriate and important.

Over the past 25 years, physician involvement in hospital governance has become the norm. A national study completed by the Health Research and Educational Trust in 2005 found that, on average, 20% of board positions in America's hospitals presently are held by physicians.* Comparable information regarding the involvement of nurses on hospital boards is not readily available. A 2005 study of 14 nonprofit general hospitals found that, in total, 52 of 203 voting board members (26%) were practicing physicians; in contrast, only 4 of the 203 board members (2%) were engaged in the practice of nursing.+ This study also found that 11 of the 14 hospital boards have established and charged a standing board committee with responsibility for monitoring the quality of patient care in their respective institutions. All 11 of these standing committees include physicians as voting members; only 7 of them (64%) included nurses as voting members.5^(pp8-9) Similar findings were obtained by a 2006 survey of governing board oversight of patient care quality in 562 hospitals. In this study, 365 of the 562 respondents (65%) indicated that nurses are "[horizontal ellipsis]involved in setting the quality agenda for the organization." The comparable figures are 98% for senior administration and 73% for medical staff.6

These data are limited and may not be representative of current governance practices in the American hospital industry. The data, however, are consistent with the situation in the nonprofit hospitals and healthcare systems with which I am personally familiar and, at the very least, they raise a series of issues that warrant serious consideration. As Donald Berwick recently stated,

It is key that nurses be as involved as physicians, and I think boards should understand 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. I would encourage much closer relationships between nursing and the board.7

Berwick is advocating for more engagement of nursing leaders in hospital governance. In that context, issues that warrant attention include the following.

* On a national basis, to what extent are nurses actually engaged as voting members of hospital boards and board committees? We need more definitive information regarding the current situation that can be updated periodically to document trends in nurses' level of involvement.

* The nursing workforce on the whole is well-educated, is large, and has a major stake in the performance of America's hospitals. What have been the barriers to nursing involvement on hospital boards and board committees? Is it just a traditional practice not to consider practicing nurses as candidates for board positions? If so, this can and should be reexamined objectively in the light of the contemporary environment and realities. Is it concern about conflict of interest? If so, this can be addressed. Nurse candidates for hospital board roles may be affiliated with that particular hospital and/or hold leadership positions in other organizations. As with physician trustees, in the case of nurses who are affiliated with the hospital where they serve on the board, the potential for conflicts of interest must be explicitly recognized and proactively addressed.*,8,9

* Could a higher level of nurse involvement on hospital boards and board committees improve communications and mutual understanding among key stakeholders within the institution about nursing issues and perspectives? I believe it would and, further, expect better knowledge and mutual understanding would be beneficial in addressing at the policy level some of vexing nursing-hospital issues that exist in many communities today.10,11

America's hospitals exist in an environment where payments for patient services are constrained; where the cost and quality of services are being questioned by governmental agencies, private payors, employers, and the public at large; where governance is being scrutinized more closely than ever before12,13; and where the nation's population and the nursing workforce are aging. Given the size and importance of the nursing workforce and nurses' impact on patient care cost and quality, it is my belief that hospital boards would benefit greatly from nurse input in boardroom deliberations and decision making.

Of course, all board members should be selected on the basis of their integrity, their commitment to the institution's mission and values, proven competence in disciplines in which the board needs expertise, and willingness to devote the time and energy required to fulfill governance duties fully and well. Like attorneys, bankers, physicians, and persons in all other disciplines, some nurses will meet these standards; some will not. To govern effectively in today's challenging environment, hospital boards should include a multidisciplinary mix of highly capable and dedicated persons. It is my belief that governance deliberations and outcomes would benefit from the engagement of respected nursing leaders around the boardroom and board committee tables. I encourage hospital board leaders and chief executive officers who have not already considered this step to do so.

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