Nurses Need a Long Drive to the Boardroom

Golf is a by-the-rules game, as anyone paying attention to Tiger Woods' controversial ball drop at the Masters tournament over the weekend can attest. The very particular rules of the Augusta National Golf Club itself are amusing. They call for no sitting in the standing areas, no standing in the sitting areas, and no fanny packs larger than 10 inches wide.

But it's the patriarchal rules of golf culture that have always baffled me. Until last year, the rules at Augusta famously and stubbornly said 'no women allowed.'

Healthcare has some patriarchal rules of its own in effect, if you haven't noticed. Now I don't think anyone in healthcare is actually saying 'no nurses allowed,' but you wouldn't know it by peeking into the C-suite. Hospital boardrooms and CEO positions are lacking representation from the largest sector of the healthcare workforce—nurses.

With the emphasis on patient satisfaction and improving the quality of healthcare, clinical experience is becoming essential to effective leadership in the hospital C-suite. Seeing physicians in hospital CEO positions and at the boardroom table is becoming more commonplace. So why aren't there more nurses among them?

Powerful leadership, under-represented
Nurses are the largest group of employees, nurses are the largest budget item, and most nurses are women. They regularly run hospitals at nights, weekends, and holidays when no other executives and rarely any physicians are around. This adaptive workforce can produce powerful leadership at the top. Why aren't nurses in higher leadership positions?

"There are issues, I think, of enormous prejudice in the system at large. When CEOs say there should be more in leadership with clinical backgrounds, they don't mean nursing, they mean medicine," says Connie Curran, EdD, RN, FAAN, a healthcare executive strategies consultant.

Despite the ratio on the front lines of patient care, only 2% of nonprofit hospital board members are nurses while there are more than four times as many nurses as physicians in the United States. While 4% of hospital CEOs in the United States are physicians, according to the American Hospital Association, even fewer are nurses, approximately 10 out of every 1,000 hospitals.

Multiple barriers prevent nurses from achieving this leadership status, but the problem, at its root, is the hierarchical structure of medicine and prehistoric gender issues that persist in healthcare.

Curran has worked in the corporate world as well as in hospitals. "I saw lots of nurses holding the place together, and many nurses in the executive branches saying 'how many CEOs do I have to teach their jobs to?' Most of these guys had a business degree and had never been above the first floor of a hospital, and they had no clue what went on upstairs."

With 94% of nurses being women, many of the barriers for women are also barriers for nurses: a lack of role models is one of them, but there's also a subtle stifling going on of this major sector of the workforce, exhibited through a lack of leadership succession training as well as a lack of recognition that nurses have the capabilities and knowledge necessary to lead a hospital.

About half (49%) of hospitals engage in succession planning, according to the American College of Healthcare Executives, but this process rarely involves nurses.

"In the corporate world… you identify these high potential individuals and you invest in them. You give them mentors and you put them on a critical path to promotion. I simply never saw that in hospitals," Curran says.

Undervalued capital
"As nurses, we undervalue our intellectual capital and others undervalue us as well, says Therese A. Fitzpatrick, PhD, RN, executive vice president of Assay Healthcare Solutions, a clinical labor management consulting firm.

Fitzpatrick and Curran coauthored the book, Claiming the Corner Office: Executive Leadership Lessons for Nurses, which tells the stories of men and women today with extraordinary careers who challenged the "traditional path" nurses take to achieve leadership positions to motivate today's nurses to think outside of the box.

"Hospitals are losing out on these leadership potentials because they're too blind to see what's right before their eyes," says nurse scholar and writer, Phyllis Beck Kritek, RN, PhD, FAAN, a speaker and consultant on conflict resolution, organizational development, leadership development, and gender and diversity.

From handling technicians to communicating with physicians and coordinating the entire care team, good nurses are trained to be effective communicators, team members, and collaborative problem solvers, all essential skills in an effective CEO, but nurses are often looked over for these positions.

Although physicians are actively saying they think they could do a better job than most hospital CEOs, physicians rarely take a business class or learn anything about organizational behavior, versus nurses whose training relies on managing relationships to do their jobs well.

Both groups, by training, lack strategic financial management experience, but physicians are still seen as the CEO candidates and continue to represent more seats in the hospital boardrooms than nurses.

"If you interview CNOs and ask if you have to keep the CMO happy, they would say yes; if you asked a CMO if they have to keep the CNO happy they would say 'no, the CNO has to keep me happy,' if they're being honest. I do think the emerging generations will change that. But the baby boomers have been pushing against a very hard wall in their careers," says Kritek.

"Doctors are upset because CNOs look too powerful. COOs and even CEOs are saying nursing is getting too powerful. What they mean by that is nurses are starting to influence the organization at the leadership level in a way that makes the others uncomfortable because nursing is often a big 800 pound gorilla in the room that they pretend doesn't exist. And nurse executives have to make a choice, do they continue to work in the organization to make a difference, or do they speak out on the issue. It's a very subtle thing," says Kritek.

HR 'bears a real responsibility'
Human resources professionals could be the driving force that eventually upends the hierarchal mentality between physicians and nurses. But they need to step up, says Curran.

"HR people who should have the skillsets and the influence, I don't think really understand what nurses do, frankly. In terms of the kind of leadership they could bring to the table, in terms of the difficult personalities nurses deal with on a daily basis, the development of their own staff," says Fitzpatrick.

"Come up to a unit, come into a hospital on a weekend, and see who is holding the place together," says Curran. "I think HR bears a real responsibility here. HR in hospitals should be providing leadership on this issue, and they should be identifying nursing talent early and emphasizing the role of the manager in developing his or her people."

The focus of a nurse's daily existence is to provide the highest quality of patient care. With such a financial emphasis around patient satisfaction and quality healthcare, a hospital CEO that prioritizes quality patient care, and understands it at its most acute level, will serve its patients well by aligning a team toward that same mission.

It was big news last August when, after 80 years, the Augusta National Golf Club changed course and invited two women to become members. Change came slowly, and only after prolonged pressure from women's groups and corporate interests.

If a similar change is to come to healthcare's C-suite, nurses need to apply more upward pressure. And HR must exert some force and be a change agent.