Khoury, Christopher M. MSc, MBA; Blizzard, Richard DBA; Wright Moore, Linda MA; Hassmiller, Susan PhD, RN, FAAN
The 2004 Institute of Medicine (IOM) report, Keeping Patients Safe: Transforming the Work Environment of Nurses, found that nurses, who comprise the largest segment of the healthcare workforce1 and spend the most time providing direct care to patients, are indispensible to patient safety and quality.2 In 2008, the Centers for Medicare & Medicaid Services3 began linking 4 quality measures influenced by nursing care into performance-based payment systems for hospitals.
The public also recognizes nurses' contributions, ranking them repeatedly as the top profession for public trust, according to a Gallup poll of honesty and ethics.4 A national survey from 2007 found that the public trusted nurses for advice and believed that nurses made their care better.5 Indeed, another recent study found that nursing is the single most important factor in how patients rate their hospital experience and whether they would recommend their hospital to a family member or friend.6
Yet, nurses are largely absent at the highest decision-making levels of healthcare services and policy making, despite the aforementioned assessments and their knowledge and understanding about how to ensure patient safety and quality. A 2008 study reviewed 201 health systems, with a total of 2,046 voting board members, and found that nurses held 2.4% of seats. In comparison, physicians held 22% of seats.7 An informal survey conducted by The Robert Wood Johnson Foundation (RWJF) and presented to the American Academy of Nursing in 2007 examined 10 large healthcare systems and found that 8 of the 118 total voting board members (8%) were nurses. The same study examined healthcare journals, and 7 of 251 board members (3%) were nurses.8
Most recently, a study of thought leaders within the healthcare workforce9 and in health policy roles found agreement that the nursing shortage was a problem and that nurses played a critical role in quality and safety. Participants in the study also acknowledged that they hear about nursing workforce issues most frequently from nursing organizations (79%). The respondents gave a low trust ranking to information coming from nursing trade associations and ranked the IOM and foundations (specifically the Kaiser Family Foundation and RWJF) as the sources they trust most for nursing workforce information. However, 2 limitations of the study were small sample size (n = 123; response rate, 41%) and overreliance on respondents in academic positions (50%).
Although both the public and those in the profession recognize nurses' vast contributions, much less is known about the views of opinion leaders already in a position to decide on and influence a variety of issues. To learn more about barriers to nursing leadership from those already in healthcare leadership positions, RWJF commissioned Gallup to conduct a national survey of opinion leaders across a broad spectrum of leadership settings and roles. This study examined views about nursing leadership with an emphasis on determining the role of nursing in the future and potential barriers to leadership roles in healthcare today.
Study Data and Methods
The survey sample targeted 1,500 opinion leaders selected across a variety of industry, academic, and government settings (See Table, Supplemental Digital Content 1, for sample demographics, http://links.lww.com/JONA/A52). Potential respondents were contacted until the sample was exhausted or a quota was achieved. If a quota was filled, any previously scheduled interviews were still completed. The sample was composed of university, insurance, corporate, and health services executives; government officials; and industry opinion leaders. The sample was purchased from Info USA (Omaha, Nebraska) and Manning Media (McKinney, Texas). From Info USA, Gallup received a count by job title of sample available from Info USA in each of the opinion leader segments. Gallup interviewers were careful to ensure that opinion leaders were at an "executive" level, with no substitutions or referrals to other personnel permitted. For example, Gallup surveyed tenured full professors, deans, and department heads, but not assistant professors. The sample was randomly selected for each opinion leader group.
Interviews for this survey (See Document, Supplemental Digital Content 2, for the full text of the survey, http://links.lww.com/JONA/A53) occurred between August 18 and October 30, 2009, during a particularly intensive period of healthcare reform policy debate in public and media settings. We randomly selected opinion leaders within each of the 6 sample categories. Prior to interviewing, Gallup sent a letter informing all participants in the study that they would be contacted by telephone to participate. The survey averaged 10.7 minutes in length.
Survey questions were developed by Gallup staff in consultation with staff at RWJF. Prior to finalizing questions, the Gallup Poll archive and outside literature were reviewed to ascertain face validity of subject matter. In addition, several opinion leaders in the field were also interviewed to obtain their insights.
For statistical analysis, we calculated means and proportions of survey question items of interest for the overall sample and the opinion leader subgroups. To determine statistical significance, we calculated 2-tailed z tests for proportions. The z test is a statistic that tests the hypothesis that 2-sample populations have the same mean or proportion, as defined by an appropriate range of values. If the value falls outside that range, there is a probability of.95 that the values for the 2 samples are different.
For a sample of 1,504 opinion leaders at the 95% confidence level, one can say that the margin of sampling error for a percentage should not exceed 3 percentage points in either direction. The telephone survey was not based on a probability sample, and therefore, researchers cannot calculate a theoretical sampling error.
The overall sample contained 5,279 phone numbers; from 4,550 numbers that Gallup contacted, 1,504 opinion leaders completed the survey: 276 were university faculty, 237 were insurance executives, 232 were corporate executives, 253 were health services executives, 253 were government policy makers, and another 253 were industry or trade association thought leaders. Final data in each respondent category deviated slightly from the targets of 250 per respondent category. Respondents came from all census regions: 21% represented the East, 28% the Midwest, 31% the South, and 19% the West.
When asked whether respondents worked in a managerial or leadership capacity in the healthcare sector at any time in their career, 39% responded yes. This group had a median of 18 years of healthcare sector experience. Seventy percent of opinion leaders surveyed were men.
Attitudes Toward Healthcare Reform Challenges
The opinion leaders viewed government (75%) and health insurance executives (56%) as the groups most likely to exert a great deal of influence on health reform, compared with only 37% for physicians and 14% for nurses (Figure 1).
Differences Among Opinion Leaders on Nurses' Influence of Healthcare Reform
Respondents from leadership roles in the government sector were significantly different (see Table 1 for all respondent proportions and significant differences) than all other respondents; 23% of these respondents said nurses have a great deal of influence in healthcare reform, compared with 14% of other individuals.
About 9 in 10 health services executives (88%) said government policy makers have a great deal of influence in healthcare reform. This percentage is significantly higher than all other respondent categories, except for insurance executives, who said government policy makers have a great deal of influence on reform (82%).
Attitudes Toward Nursing Influence in Planning, Policy, and Management
Survey respondents may not view nurses as having a great deal of influence on health reform, but they said nurses have a great deal of influence (Figure 2) on the key elements of a quality healthcare system. A majority of opinion leaders (51%) said nurses have a great deal of influence in reducing medical errors and improving patient safety, and 50% said nurses exert a great deal of influence on improving the quality of patient care. A minority of opinion leaders (18%) said nurses exert a great deal of influence on increasing access to care, including primary care.
Attitudes Toward Nursing Shortages
Overall, 4 of 5 opinion leaders said there is a nursing shortage in the United States. University faculty members were significantly more likely to say there is a shortage, whereas corporate executives were significantly less likely to say one exists. Among those who said there is a shortage, 45% said it is a very serious problem, and 53% said it is somewhat serious. The most frequently cited reasons for the nursing shortage included a stressful or poor work environment (44% say this is a very important reason), not enough openings for students in nursing schools (40%), and too many nurses leaving the profession (37%).
Identifying Barriers to Nurses Having a Voice in Healthcare Reform
The principal barriers (Table 2 shows a breakdown of barriers by survey respondent type) to nurses having more influence and exerting more leadership include perceptions of their role as key decision makers when compared with physicians (69% of respondents say physicians are the key decision makers) and perceptions of their role as revenue generators (68% of respondents say physicians, not nurses, generate revenue). Thirty-one percent (31%) identified the media's depiction of nursing as a barrier.
Differences Among Opinion Leaders in Identifying Barriers
The majority of university faculty identified the 2 most important barriers as nurses not being perceived as important decision makers (82% report as a major barrier) and physicians, not nurses, being seen as revenue generators (77%). Other groups surveyed, including insurance executives, corporate executives, and health services executives, also cited these 2 factors as barriers, but with less intensity (Table 2).
Government opinion leaders ranked lack of opportunity to advance as a greater barrier than the other groups. In addition, both government leaders and industry leaders said relatively poor compensation for nurses is a more significant barrier to leadership, than did insurance executives, corporate executives, and health services leaders.
Analysis of Open-Ended Responses
We asked respondents to offer suggestions for how nurses could take on more leadership in improving and delivering health and healthcare. Gallup coders reviewed each verbatim comment for key words or themes. These common words or themes were then assigned codes or titles. Foremost among respondents' comments was that nurses need to make their voices heard (15% saying so). Opinion leaders viewed nursing as lacking a single, unified voice to focus on key issues in health policy and viewed many nurses as lacking interest in taking on this role. Second most frequent, opinion leaders felt society, and nurses themselves, should have higher expectations (12% saying so) for what nurses can achieve. In other words, respondents felt nurses should be held accountable for not only providing quality direct patient care, but also for healthcare leadership. Gallup researchers examined individual verbatim comments within these 2 themes and uncovered 5 perceptual barriers, which are discussed below.
Nurses Are Not Prepared for Leadership Positions
Respondents viewed nurses more as bedside clinicians than healthcare leaders and system decision makers. Some felt, however, that nursing leadership is possible with more education for nurses. Some opinion leaders commented that eliminating 2-year degrees and requiring all nurses to have, at a minimum, 4-year degrees would bring nursing in line with leaders from other health professions. Some suggested that additional specialty certifications and graduate-level education would provide more preparation for leadership.
Many saw leadership, management, and financial skills as lacking or underrepresented in current nursing education curricula. Some leaders held the opinion that training should remain focused on bedside care. They were consequently concerned about exacerbating the shortage of bedside nurses if more nurses migrate to leadership positions. Some viewed 2-year degrees as the solution to the shortage of bedside nurses, supplemented by higher skill levels and leadership from 4-year and more advanced degrees. Others were simply confused by all the levels of nurse training and saw that as part of the problem.
Nursing Shortages Reduce the Chances for Nurses to Exhibit Leadership
These opinion leaders saw the first priority as increasing the supply of bedside nurses and did not want to divert attention from this issue. They asserted that if the supply of nurses increased and staffing challenges improved, more nurses would have the time and inclination to exhibit leadership skills and to pursue opportunities to develop talent beyond the bedside. Others said improved pay, less stressful working conditions, and better recognition of nurses' essential role in healthcare would boost the supply of nurses.
Physicians Play the Primary Role as Leaders in Care Provision
To some opinion leaders surveyed, it was clear that physicians, with their ability to generate revenue, hold the most prominent positions of power. In response to open-ended questions in the survey, respondents identified scope of practice conflicts as a barrier to innovative team approaches to the practice of medicine. For instance, a chief medical officer interviewed had done a literature search of the term "collaboration." He asserted that all such references were in the nursing literature and none in the physician literature.
Some respondents viewed education and training as key, noting the traditional separation of nurse and physician training. For instance, a few respondents suggested a better practice might be the European approach of training physicians and nurses together.
Survey respondents viewed the current health reform environment as providing an opportunity for changing the care model and modifying the role of nursing. Respondents mentioned models such as the technology-equipped medical home and the outpatient clinic as a communication hub. Respondents noted that if prevention is a solution to controlling healthcare costs, nurses traditionally have filled roles in community and public health settings.
Nursing Organizations Need to Position Nurses as Professionals Who Deliver Care
Some opinion leaders indicated that the American Nurses Association (ANA) acts like a union, and the American Medical Association acts like a professional association. Perceptions of the ANA's role in the nursing profession may be unclear. One respondent in the health services industry commented, "It marginalizes nurses when the only national leadership voice is coming out of unions." Their perception was that unions are for workers in production roles, not for management and leadership. In other words, they believed the nursing profession hinders itself when it positions itself as a union rather than a profession.
Nurses Vary in Their Aspirations to Lead
These groups of opinion leaders questioned whether nurses want to play leadership roles. They saw nurses as entering the workforce with the intent to practice at the bedside. They viewed nurses as bedside caregivers following orders from physicians. They asserted that students who are currently attracted to the nursing profession prefer direct patient care and may resist a shift to management and leadership roles. These opinion leaders argued that if nurses are to become leaders, they should be recruited for their leadership potential, not simply traditional nursing skills.
Gallup based this study and subsequent discussions on opinion leaders' perceptions. As in any opinion-based study, opinions may not always be an accurate reflection of objective reality. Individuals filter experiences through their previous experience and predispositions. This leads to the potential for wide variations in interpretation of the same objective event. Although care was taken to appropriately sample a wide range of opinion leaders, other researchers may more narrowly or broadly define this group. Finally, our questionnaire was administered at a time when the subject of healthcare reform was more prominently in the public debate, potentially affecting respondents' views.
Our study uncovered findings from the perspective of opinion leaders-those already in positions of power and influence across a spectrum of professions and roles. Implications for nurses and nursing leaders are 3-fold.
First, a renewed emphasis must be put on developing management skills. Many nurses are not prepared to assume and thrive in leadership positions because of a lack of formal management training. Nurses need to develop basic management and problem-solving skills. Leadership skills must be learned and mastered over time. Potential leaders must be recruited, identified, and developed. Nursing training and education programs must be developed to address skill and knowledge needs of management disciplines.
Second, operational excellence and continuous process improvements must be tackled. Nurses spend an excessive amount of time fixing problems caused by broken and inefficient processes and systems. This is accentuated by the need to interact with so many different departments and services. Improving process efficiencies will allow nurses to spend more time on providing more direction and knowledge while performing leadership functions.
Finally, nursing workload must improve. Lack of time to complete necessary care and administrative tasks can leave nurses little time to devote to healthcare leadership. For managers, this is aggravated by large spans of control. Nurse managers must be better supported in developing delegation skills and given tools to reduce patient care and administrative burdens.
The authors thank Ms Coleen McMurray and Dr Frank Newport for their expertise and guidance in the development and analysis of this survey and extend thanks to Jaimie Kelley for research and editing services.
© 2011 Lippincott Williams & Wilkins, Inc.