In a recent editorial by Adams, Glassman, McCausland, Pappas, and Manges (2019), nurses are called to demonstrate and amplify their influence to advance health and health care. The call to action’s urgency is poignantly articulated with this triggering passage, “Nurses’ contributions are often completed while leading quietly from the back. This, however, likely has a limiting and possibly a detrimental effect on the health of our population” (Adams et al., 2019, p. 398). The tendency for nurses to lead in quiet ways is being replaced by bold and courageous disruption as we recognize our value, our contributions, and our influence in society.
During this Year of the Nurse and Midwife designated by the World Health Organization, the profession is reflecting on the past 200 years of modern nursing. Targets have been set to further develop nurses as leaders and advance nurses’ influence across policy, research, practice, education, theory, media, and industry (Adams et al., 2019; World Health Organization, 2019). The range of these target areas is testimony to the comprehensive ways that nurses impact health and health care, and they present an opportunity to think differently about how nurses can better meet the needs of populations. In response to the call to amplify nurses’ voices, we discuss nurses’ leadership influence as it intersects with three areas of governance: (a) clinical practice, (b) boards of directors, and (c) health policy. Finally, we offer assessment and strategic participation recommendations that can be used to advance nurses’ influence.
For many nurses, the concept of governance is shrouded in mystery. Governance is a multilayered concept that applies in a wide range of settings; however, we generally think of governance only in terms of governments. Other definitions of governance include actions aimed toward caring in a supervisory way or decision-making (Merriam-Webster, Inc., 2020). All of these definitions of governance are relevant to nurses’ influence within organizations and more broadly in society. Furthermore, all nurses have the opportunity to amplify and elevate their influence to improve health and health care systems through governance.
Governance Influence in Clinical Practice
In clinical practice settings, shared or professional governance structures promote the inclusion of nurses’ knowledge, skills, and expertise in organizational decisions. Such formal governance structures provide pathways for nurses’ professional empowerment and influence to shape organizational procedures and policies (Porter-O’Grady, 2017). Considering the Quadruple Aim goals to improve quality, reduce costs, improve the patient experience, and improve the well-being of care teams (Bowles, Batcheller, Adams, Zimmermann, & Pappas, 2019), nurses’ participation in shared governance has tremendous influence over metrics that are meaningful to organizational performance, patient outcomes, and workforce health. With workforce health so critical for overall organizational performance and clinical outcomes so dependent upon nurse-sensitive quality metrics, participation in shared governance committees and processes is a meaningful way for nurses to amplify professional influence.
Nurse leaders, educators, and professional development specialists are well positioned to provide leadership development and support for nurses engaged in shared governance councils. The Leadership Influence Over Professional Practice Environments Scale is recommended for nurse leaders interested in creating supportive clinical practice environments, positive patient outcomes, and organizational performance (Adams, Djukic, Gregas, & Fryer, 2018). This instrument measures nurses’ leadership characteristics related to nurse-sensitive patient metrics and may be useful for bolstering models of shared governance in organizations. In a recent study, nurse influence was found to be a core quality of healthy work environments, along with advocacy and innovation (Bowles et al., 2019). What begins as leadership influence in clinical practice shared governance can be leveraged across organizations and into communities, thus expanding nurses’ sphere of influence.
Governance Influence in Boardrooms
Expanding influence beyond clinical practice, nurses who serve on boards of directors are positioned to influence decisions that support organizational strategic direction, structures, processes, and performance (Prybil, Popa, Warshawsky, & Sundean, 2019). Whether in health care settings, civic organizations, or corporations, board members make strategic decisions that determine which major service lines are supported by the organization and how and where resources will be allocated. Research suggests that health care organization performance is stronger when at least one nurse serves on the board (Szekendi et al., 2015). With knowledge of communities and population health needs, nurses who serve on organizational boards of directors lend critical insight into governance discussions and decisions that positively impact organizational performance, patient outcomes, and population outcomes (Sundean, Polifroni, Libal, & McGrath, 2018).
Bolstering the number of nurses who are prepared as board leaders increases the likelihood that more nurses will be ready and willing to serve on boards. Board preparation programs and resources are becoming increasingly available. Programs are more readily available online, face-to-face, and via books like Nurse on Board: Planning Your Path to the Boardroom (Curran, 2015). A recent journal article offers strategies for incorporating governance education into nursing education curricula from prelicensure through graduate levels (Sundean, White, Thompson, & Prybil, 2018). The Nurses on Boards Coalition website provides a convenient hub for nurses to be counted among all nurses nationally who serve on boards, to be connected to boards in search of nurse board leaders, and to share their narratives about board impact (Nurses on Boards Coalition, 2020). Nurses can also assess their readiness for health care board governance roles using the Healthcare Board Competency Survey for Nurses (Sundean, 2017). Connecting governance acumen within industry-specific knowledge strengthens nurses’ influence, capacity, and confidence, which transfers to broader settings.
Governance Influence in Policy
Leadership and influence skills are relevant for nurses participating in all levels of health policy (local, state, federal, and global). Health care is a significant voting concern for U.S. citizens, and although nurses are trusted and knowledgeable, their participation in health policy is limited (Cohen & Muench, 2012; Hrynowski, 2020; Richter et al., 2013).
Actively engaged nurses are welcome partners to influence policy in local, state, federal, and global communities. Montalvo (2015) identifies political awareness and social astuteness as essential skills for health policy leadership, and Waddell, Adams, and Fawcett (2018) emphasize the importance of clear communication and understanding the context for policy interpretation (who is making decisions and when deliberations will occur) to influence policy. Professional lobbyists or government relations professionals can assist with understanding policy context, political navigation, and strategy to strengthen nurses’ policy contributions (Waddell, Audette, DeLong, & Brostoff, 2016).
Policy influence is related to media savvy, and media plays a powerful health care influencer role. However, nurses are often “invisible” in health and news media policy. To increase visibility, nurses are encouraged to work with communications experts to amplify their knowledge and expertise by leveraging media influence (Mason et al., 2018).
Advancing nurses’ participation and influence in policy is essential for the profession. Walton, McLennan, and Mullinix (2020) suggests that nurses need multiple nudges of encouragement to seek board roles and to participate in health policy (Waddell et al., 2016). Resources to support nurses’ policy participation skills are available on the websites of many professional nursing organizations (American Academy of Nursing, 2020; American Nurses Association, 2020; American Organization for Nursing Leadership, 2020). Hospitals are also beginning to provide education to support nurses’ policy participation, and nursing education curricula increasingly includes health policy as an essential component in baccalaureate, master’s, and doctoral education (Ellenbecker et al., 2017; Waddell et al., 2016). Professional development specialists and clinical educators support the development of nurses’ influence skills and can encourage participation in governance structures from shared and board governance to health policy participation.
Each area of governance discussed (clinical practice, boards of directors, and health policy participation) focuses on nurse leaders as influencers. Given the breadth of the different levels of governance leadership, it is evident that nurses can and should lead from wherever they are. Regardless of formal titles and positions, nurses are called to expand their sphere of leadership influence through knowledge, skills, expertise, participation, and bold action.
Primary care is a good example of a space where nurses can lead boldly and with influence to transform health care. The national population tops nearly 400 million, and virtually everyone needs some amount of primary care. However, a major gap in our health care system is the ability to meet primary care needs as a result of lack of providers and lack of access. With nearly 4 million nurses in the United States, we have the power and influence to shift health care priorities toward the upstream benefits of primary care. By practicing at the top of our licenses, modernizing scope of practice legislation, focusing on the social determinants of health, and developing innovative models of care, nurses can and should lead efforts to prioritize primary care as a means of transforming health care. In policy language, this is an idea whose time has come (Dye, 2016). Using primary care as one example, nurses are urged to be influential leaders through governance in clinical practice, on boards of director, and in policy settings.
The Adams Influence Model is useful for nurses in all spaces to reflect on leadership influence. This model also serves as the theoretical underpinning for the Leadership Influence Over Professional Practice Environments Scale, the Leadership Influence Self-Assessment, and the Waddell Spectrum for Policy Participation Influence and Research Instrument (Adams et al., 2018; Adams & Natarajan, 2016; Shillam et al., 2018; Waddell, 2019). The Leadership Influence Self-Assessment instrument is recommended for individual nurses as a starting point for identifying leadership opportunities, decision-making acumen, and strategic vision (Shillam et al., 2018). The Waddell Spectrum for Policy Participation Influence and Research Instrument (a) addresses the extent to which nurses apply expertise to identify, inform, and influence efforts to improve health policy and (b) provides insights into nurses’ strengths and areas for growth in policy participation (Waddell, 2019). Each instrument, along with the Adams Influence Model, provides a strong base of support for leadership influence in health care and more broadly in society.
Nurses, 4 million strong, can no longer be the silent majority. Time is running out for the profession to lead quietly from behind (Adams et al., 2019). We identified multiple opportunities for nurses to impact health and health care through leadership influence across clinical practice, on board of directors, and as health policy drivers. In addition, we considered tools for nurses to hone their leadership and influence skills. Nurses in leadership, education, and professional development roles are positioned to unlock doors and mentor the development of junior nurses, which ultimately leads to a more influential profession. As this Year of the Nurse and Midwife marches on, all nurses are urged to participate in governance, join conversations, and boldly advocate change for a healthier society led by an influential nursing profession.
The authors would like to acknowledge Susan M. Grant, DNP, RN, FAAN, and Maureen P. McCausland, DNSc, RN, FAAN, for their review and feedback in the development of this editorial.
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