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Feature: CE Connection

Leading for change

Nurses on boards

Dorritie, Richard PhD, RN; Fiore-Lopez, Nicolette PhD, RN, CNEP; Sonenberg, Andréa PhD, WHNP, CNM-BC, FNAP, FNYAM

Author Information
Nursing Management (Springhouse): March 2020 - Volume 51 - Issue 3 - p 14-20
doi: 10.1097/01.NUMA.0000654844.72394.8f
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The landmark 2010 Future of Nursing report recommended that nurses should be full partners, with physicians and other healthcare professionals, in redesigning healthcare in the US.1 In response to this recommendation, and to ensure that all eight recommendations are implemented, the Robert Wood Johnson Foundation (RWJF) in collaboration with AARP founded the Future of Nursing: Campaign for Action—a “nationwide initiative designed to harness the power of nursing to help all Americans lead longer, healthier lives.”2,3 One of the initiatives born out of this campaign is the Nurses on Boards Coalition (NOBC), which is implementing a national strategy to improve the health and well-being of the nation by bringing nurses' valuable perspectives to myriad governing boards, state-level and national commissions, and other decision-making bodies, with the overarching interest to promote a culture of health. In partnership with the RWJF and AARP, the NOBC first convened in 2014 with a guiding principle that building healthier communities in America requires the involvement of more nurses on corporate, health-related, and other boards, panels, and commissions.2 The NOBC represents nursing and other organizations working to build a stronger nursing presence on such boards, panels, and commissions, with the original goal of 10,000 nurses by 2020.

As the nation's health is impacted by a variety of determinants, nurses' expertise and holistic viewpoints are invaluable resources when making health, educational, environmental, economic, and transportation decisions, as well as for other social policies and regulations. Despite the US Department of Health and Human Services' Heckler Report being published over 3 decades ago, the US healthcare system continues to be challenged to improve persistent health inequities.4 Throughout the years, there have been several systemic efforts to close the disparities gap through health system reform, the most recent effort being the passage of the Affordable Care Act into law in 2010.5

Multiple factors influence population health outcomes. Many have said that an individual's zip code is a greater predictor of health than his or her genetic code.6 Social and environmental determinants, unlike biologic determinants such as birth sex and genetic code, are targets with the potential to be influenced, mitigating their risk(s) to health. For example, education, socioeconomic status, and environmental factors often contribute to the disparities seen among various populations. One avenue to mitigate these factors is through reforming social and environmental policies. Nurses are often viewed as experts in holistic approaches to population health, assessing the myriad determinants affecting the well-being of patients, families, and communities. This broader perspective facilitates addressing and mitigating the risks posed by these determinants through collaborative and innovative strategies as contributors to board and task force work.

Although having nurses on healthcare organization boards is incredibly important and significant, many societal decision-making entities have the potential to impact health. Nurse representation on decision-making bodies within the healthcare industry contributes experience and a holistic perspective to care delivery; however, this same rounded worldview and input may often be absent at the community level. Nurses on boards beyond the healthcare industry can bring their unwavering advocacy for wellness and health promotion from the client and patient perspective to corporations, parent-teacher associations, and community groups, as well as nongovernmental and governmental organizations.

Having nurses at the table in these many venues provides stakeholders with expertise on a variety of health-related perspectives, including the patient experience and quality and safety, contributing the viewpoints of the largest proportion of the healthcare and hospital workforce. Nurses possess the skills and experience needed to bring new perspectives and positive changes to boards, coalitions, and collaboratives in all areas of our communities. This article presents the history, mission, processes, goals met, and lessons learned of the New York State Action Coalition NOBC (NYSAC-NOBC).

History

The NYSAC is the driving force for implementing the Future of Nursing report recommendations in New York State, working with diverse stakeholders to create and model innovative solutions for healthier communities, with nurses often leading the way.1 The NYSAC-NOBC works at the local and state level to develop strategies and identify opportunities to increase the presence of nurses on corporate and nonprofit boards of directors, commissions, expert advisory committees, task forces, and other organizational decision-making bodies. The NYSAC-NOBC shares the same structure as the NYSAC—its parent organization—having seven regional divisions, with at least one committee member representing each.

The NYSAC-NOBC was inaugurated in 2015 as a group of approximately 15 nurse leaders throughout New York State. Each of the committee members was specifically chosen through state nursing contacts to establish a diverse group, representative of the seven geographic regions. Over the life of the NYSAC-NOBC, members have left for various reasons, such as relocation, conflicts in scheduling, or changes in interests, and committee representation has dwindled occasionally as several members left without succession planning. The committee became concerned that without adequate statewide representation among its members, the vetting processes of candidates for board placements wouldn't be as robust. The committee discussed strategies to recruit a more representative membership, reaching out to NYSAC members at large for recommendations and required succession planning for all future member resignations.

Early on, it was determined that the success of the committee would be due, in part, to sustaining its statewide representative composition, recognizing that a regional communication structure was essential for maintaining efficiency and effectiveness. New York State nurses' contact information and level of interest and/or current service on a board was regularly received from the national NOBC, which the NYSAC-NOBC then combined with curricula vitae (CVs) solicited at the state level. The committee filed each newly received CV, by the nurse's residence and/or place of employment, to its assigned state regional digital folder. The regional folders, housed in a secure, shared collaborative drive, facilitate the vetting efforts of NYSAC-NOBC members.

It's vital that when solicitations are received for nurses to be recommended to a board or other appointment, members of the NYSAC-NOBC are able to review their region's folder. NYSAC-NOBC members may have firsthand knowledge of a nurse whose CV is in their regional folder or can reach out to local colleagues who may be able to assist. By vetting the CVs of potential candidates, the committee can recommend the best candidate for the board opportunity (either those that the NYSAC-NOBC secures or those that the national NOBC disseminates) and enhance the likelihood of a successful appointment for each recommendation.

Mission

The national NOBC has five strategic imperatives for 2017-2020:7

  1. facilitate board placements
  2. create a dynamic organization
  3. promote collaboration
  4. demonstrate the impact of nurses on boards
  5. develop synergy.

At the state level, the NYSAC-NOBC focuses primarily on facilitating board placements and developing member synergy and value. Initially, the primary goal was for the committee to identify board service opportunities and attempt to fill those seats with qualified nurses. The second goal was to educate nurses in the skills necessary to serve on a board. This training was a prerequisite for qualifying nurses for the board positions.

Data have been key to tracking and growing our progress. Recently, the NYSAC-NOBC secured a collaboration with the Foundation of New York State Nurses' Center for Nursing to provide a web presence, which will allow for a public showcase and celebration of the successful appointments of New York State nurses to board positions, link to local and national training events and materials, and provide a simple and secure repository for interested nurses to upload their CVs for board placement consideration.

One of the primary strategies of the NOBC has been to help prepare nurses to serve on boards. The NOBC website contains information for nurses on how to select a board and become a valued board member. Early work identified potential areas for which education was needed, such as skills and knowledge around fiduciary responsibility and financial commitments.8 Members of the NYSAC-NOBC, often working together or collaborating with nurse experts in board service, developed and disseminated lectures, slide decks, and full-day training programs. These programs were designed for sharing and the broader training of nurses at large. The work was informed, in part, by a growing knowledge base on the needs of nurses filling leadership positions.9

Carrying the mission of preparing nurses to “lead change and advance health” one step further, it's logical that this preparation should begin during formal nursing education.1 The American Association of Colleges of Nursing Essentials have long included and promoted competencies in organizational and systems leadership, including to “participate in the design and implementation of new models of care delivery and coordination.”10,11 Developing and promoting nurse leadership must go beyond the confines of providing care; this entails educating nurses in the professional leadership and governance roles integral to patients and, more broadly, health systems and advocacy. Nurses can benefit from current, highly visible nurses, such as Congresswoman Lauren Underwood, Rep. Eddie Bernice Johnson, and Delaware's 26th Lt. Governor Bethany Hall-Long, as examples of nurse leader role models from beyond the bedside and healthcare organizations.

A primary healthcare worldview must be the context, recognizing the impacts of the social determinants of health. The steps that followed were to train and empower nursing educators and nurses to be seated on the boards of any decision-making organizations whose missions impact health, wellness, and livelihood. However, achieving the NOBC goal of 10,000 nurses on boards by 2020 can't be done solely by training and recruiting nurses who desire to have a seat at the table. Educating stakeholders about how a nurse on their boards, committees, and task forces benefits their organization and helps them meet their missions is an essential step in securing nurses' seats in these leadership positions. Summarized in Table 1 are the several strategies that the NYSAC-NOBC members used to solicit board and task force positions.

Table 1
Table 1:
Examples of NYSAC-NOBC board activities

Processes

As the Future of Nursing report recommendations gave birth to action coalitions and subsequently the NOBC, there was a call for an increased dedication to data collection and improved information infrastructure.1 When the NYSAC-NOBC was established, there was very limited information on nurses occupying leadership positions. In almost all instances, it was exclusively in healthcare organizations.12

Having started without any data, the NYSAC-NOBC designed a survey to identify nurses who were interested in or already serving on boards, on which boards they served, and whether they were interested in mentoring and/or succession planning. By early 2017, it became clear that there was a benefit to collecting these data at the national level exclusively and not overburdening respondents. The NYSAC-NOBC contributed more to the overall progress of the Future of Nursing: Campaign for Action by directing all respondents to the national NOBC. This facilitated effective central accounting of nurses' board memberships and for NYSAC-NOBC to receive regular periodic reports of New York State data from the national NOBC.

To securely store, view, and edit our data, the NYSAC-NOBC used collaboration applications such as an internet-based shared drive. The NYSAC-NOBC regional coleaders and other supporting members joined in virtual meetings to carry out two main elements of the committee's mission: identifying and placing nurses in board positions and supporting nurses to gain interest and necessary experience to assume a board position.

Goals met

Since its inception in 2016, the NYSAC-NOBC has been making strides toward meeting its mission, as indicated by national and state trends of board positions held by, or new appointments of, New York State nurses. (See Table 2.) However, the progress has been slow and there's still much work to be done to achieve the goal of 10,000 nurses on boards nationally by 2020. To date, with a New York State population of 19.5 million (6% of the total US population of 327 million), 338 New York State nurse board appointments currently represent approximately 3% of all counted board service. Although no state-level goals were made, if New York counted board members at a rate equal to our population, it would be approximately 600.

Table 2
Table 2:
National and New York State nurses on boards statistics13

As is often experienced by many committees, one of the challenges to be addressed was how to maintain and engage NYSAC-NOBC members while simultaneously recruiting new members. The committee recognized that collaborating with professional New York State nursing organizations could facilitate recruitment. The regions represented on the NYSAC-NOBC appointments committee mirror the regions that comprise the New York Organization of Nurse Executives and Leaders (NYONEL). In fact, a working relationship was established with the NYONEL as the goals of the committee and NYONEL were aligned. Over the years, a report on the committee's work has been provided to the NYONEL on a periodic basis to share with its board and disseminate to its members.

Late in 2018, the committee cochairperson was solicited through the NYONEL program committee to present the NYSAC-NOBC's work. The committee saw this as an opportunity to educate the representative nurse executives and leaders in New York State about the committee's work and why it matters and to recruit new committee members. Several NOBC members developed a presentation, which was delivered at the 2019 NYONEL Annual Meeting and addressed the following key areas: the background for establishing the NYSAC-NOBC, what nurses need to know about boards, activities of the NYSAC-NOBC, a proposed research study (by a group of NYONEL members), and a panel of nurses who are on boards. As a result of this presentation, the NOBC gained four new members from the upstate regions of New York State. The infusion of new committee members has reinvigorated the NYSAC-NOBC and resulted in several more nurses being vetted and put forth as candidates for board placements.

Lessons learned

Over the life of the committee, and through discussions at other professional venues, several issues impacting nurses fulfilling board service have come to light and are worthy of further discussion.

Nurses appointed to boards must actively participate. They must speak up and step up by raising important questions, making important observations and suggestions, volunteering to serve as committee chairs, attending events, networking with their colleague members on the board, helping spread the organization's work via social media, being visible with the organization's leadership, and using the opportunity to serve on a board as a vehicle to enhance the board's knowledge of how nurses can contribute in unique and meaningful ways.

Nurses can use networks and organizational strength to fulfill the financial requirements of nonprofit boards. Many nonprofit boards have the expectation that board members either give or get financial contributions for the organization, meaning either fundraising a fixed dollar amount or contributing the same. Although nursing has been, and still is, a profession that resides at the low end of the pay scale in comparison with traditional board members, such as lawyers, business executives, bankers, accountants, and physicians, creating networks of nurses willing to donate allows for sharing this financial burden. There exists substantial ethical rationale for individual nurses supporting each other as a method of supporting the profession. Additionally, when nurses sit on a board in a leadership position, they're also advancing the names of organizations with which they've been affiliated. In many cases, these organizations can be tapped to provide financial support.

Organizational nurse leaders, such as deans, CNOs, and CEOs of health-related organizations, should be counted on to support nurses in these critical roles. Their support comes, in part, because of their high visibility and what's likely to be a higher level of remuneration. These individuals are also better positioned to leverage the support of their organizations and they're in an ideal position to identify aspiring nurse leaders or students whose interests align with the organization's mission. Future work is needed to evaluate the impact of nurses in board positions.

A seat at the table

To fulfill the recommendations of the Future of Nursing report, nurses must rise to the call to lead health system reform. This can begin on a smaller level of committees, task forces, and boards—those representing healthcare and those going beyond—recognizing that there's “health in all policies.” With their vast experience and holistic worldview, nurses are uniquely positioned to lead. Now, they must commit to fulfilling the mission of their profession by seeking the necessary training, honing their skills, mentoring novice nurses, and developing the confidence to take a seat at the table.

INSTRUCTIONS Leading for change: Nurses on boards

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REFERENCES

1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.
2. Campaign for Action. Join the effort to get 10,000 nurses onto boards by 2020. 2014. https://campaignforaction.org/join-effort-get-10000-nurses-onto-boards-2020.
3. Hassmiller SB. The Future of Nursing Campaign for Action: state-level implementation efforts. Nurs Outlook. 2011;59(5):292–293
4. US Department of Health and Human Services. Report of the Secretary's Task Force on Black and Minority Health (Heckler Report). Washington, DC: US Department of Health and Human Services; 1985.
5. US Congress. H.R.3590—Patient Protection and Affordable Care Act. 2010. http://www.congress.gov/bill/111th-congress/house-bill/3590.
6. Dwyer-Lindgren L, Bertozzi-Villa A, Stubbs RW, et al Inequalities in life expectancy among US counties, 1980 to 2014: temporal trends and key drivers. JAMA Intern Med. 2017;177(7):1003–1011.
7. Nurses on Boards Coalition. 10,000 nurses on boards by 2020. http://www.nursesonboardscoalition.org.
8. Mason DJ, Keepnews D, Holmberg J, Murray E. The representation of health professionals on governing boards of health care organizations in New York City. J Urban Health. 2013;90(5):888–901.
9. Walton A, Lake D, Mullinix C, Allen D, Mooney K. Enabling nurses to lead change: the orientation experiences of nurses to boards. Nurs Outlook. 2015;63(2):110–116.
10. American Association of Colleges of Nursing. AACN essentials. http://www.aacnnursing.org/Education-Resources/AACN-Essentials.
11. American Association of Colleges of Nursing. The essentials of master's education in nursing. 2011. http://www.aacnnursing.org/Portals/42/Publications/MastersEssentials11.pdf.
12. Sundean LJ, Polifroni EC, Libal K, McGrath JM. Nurses on health care governing boards: an integrative review. Nurs Outlook. 2017;65(4):361–371.
13. Nurses on Boards Coalition. NOBC data report emails. 2016-2019.
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