The nursing profession has long valued and emphasized the importance of leadership from the bedside to all levels of organizations.The nursing profession has long valued and emphasized the importance of leadership from the bedside to all levels of organizations. The global pandemic, and continued focus on quality, accessible healthcare, and healthcare costs in America, highlights the need for nurses to be at the center of decision making at all levels (National Academies of Sciences, Engineering, and Medicine [NASEM], 2021). Involvement at the board level allows nurses to create institutional processes to improve the delivery of services, set policies, and establish benchmarks to address pressing issues.

...nurses are professionally prepared to offer a substantial contribution at the board level.Nurses are accustomed to balancing interests and power of stakeholders when advocating and participating in the creation of policy (Patton, Zalon, & Ludwick, 2018). Additionally, nurses understand complex clinical situations, unique relationships with patients, perspectives on quality and safety. This understanding, and leadership knowledge and experiences, ideally positions them to serve as leaders not only in healthcare operations, but also at the board table (Hassmiller & Combes, 2012; Judge & Lewis, 2016). As such, nurses are professionally prepared to offer a substantial contribution at the board level.

The past decade yielded a number of discussions regarding the value that nurses bring to leadership at the board level. Consequently, supportive agenda-setting statements have been published by organizations such as the American Hospital Association’s Center for Healthcare Governance and Health Research & Education Trust (Cornwall & Totten, 2007); the National Academy of Medicine, formerly the Institute of Medicine (2011); and the Robert Wood Johnson Foundation (2014).

The number of nurses on boards is now over 10,000Emboldened by efforts of the National Nurses on Boards Coalition (NOBC), many nurses have actively pursued board service. The number of nurses on boards is now over 10,000 (NOBC, 2021). Board contributions of nurses are growing and are increasingly recognized in the nursing literature (Cleveland & Harper, 2020; Harper & Benson, 2019; Harper & Wray, 2019). The increased number of nurses on boards support health reform efforts that promote healthcare value and provide access to care (Khoury, Blizzard, Moore, & Hassmiller, 2011; Reinhard, 2017). It is no longer a question of whether nurses are serving on boards, but how to best place and prepare nurses to raise their voices at the board table to make contributions that increase the health of communities and populations they serve.

It is no longer a question of whether nurses are serving on boards, but how to best place and prepare nurses to raise their voices at the board table...

There is evidence to support the outcomes of nursing leadership in the clinical area and recognition that this leadership extends to the board level. Professional organizations have identified that the unique disciplinary knowledge attributed to nurses supports the role of nurses in the boardroom. The literature indicates that their knowledge, skills, and perspectives should be helpful to meet obligations for evaluating nurse effectiveness at the board table (Cleveland & Harper, 2020; Harper & Benson, 2019; Mason, Keepnews, Holmberg, & Murray, 2013; Sundean, 2017; Sundean, Polifroni, Libal, & Mcgrath, 2018). However, no research exists to identify which skills nurses find most helpful in executing their board responsibilities and what experiences lead to attainment of these skills. Further, few studies have reported experiences that nurses find helpful to meet obligations or evaluate their effectiveness at the board table. Existing evidence that links board member responsibilities to nurse leadership experiences and effectiveness as board members is limited in scope, leaving naysayers critical of the role nurses can play (Mason et al., 2012; Sundean, 2017).

The purpose of this study was to develop a repository of clear and relevant items that could be used to establish an instrument to measure nurses’ professional experiences and responsibilities as board members. Generally, using the instrument will provide insight into how nurses function as board members. Understanding the professional experiences that nurses perceive as valuable will inform professional development activities for those interested in board service and can be used to engage them in board work earlier in their career. Measuring nurse member effectiveness in executing board responsibilities will help prepare nurses to serve on boards and help others see how they are effective in their role as board members. Further, the tool could be used for self-assessment by nurse board members who desire to strengthen their performance.

...few studies have reported experiences that nurses find helpful to meet obligations or evaluate their effectiveness at the board table. The results of our work expand the body of knowledge surrounding nursing presence on boards through the identification of experiences and board member responsibilities that link the unique disciplinary contributions of nurses to organizational governance. In this article, we describe the results of this exploratory phase of our mixed methods analysis. We also wish to communicate the rich nature of discourse and the themes that evolved from that discussion as a mechanism to inform ongoing efforts to study the experiences and impact of nurses on boards.

Methods

Design
This article presents findings from the first phase of an exploratory, sequential, mixed methods research study. The design included three methods of data collection: an extensive review of the literature for relevant items; a survey; and focused discussion groups. The study was approved by the university institutional review board.

Examples of experiences include nurse mentorship and professional nursing association membership. Relevant Items. Initially, an extensive review of the literature was conducted to analyze literature from a variety of disciplines, including nursing and business. Two item repositories were created based on this review. One repository contained 86 items intended to capture nurses’ professional experiences that were useful to prepare for board activity. Examples of experiences include nurse mentorship and professional nursing association membership. The second repository contained 57 items intended to delineate board member responsibilities. Examples of items include contributing to the strategic plan and monitoring regulatory compliance. Each item in the repositories was reviewed by a panel of experts for content validity.

Survey and Focus Groups. In this phase of the study, we then collected data via an electronic survey and focus group discussions to determine the relevance and clarity of the repository items. Participants were recruited via email. Prior to attending the focus group, participants completed the survey, which contained questions related to demographics and the 143 items from the two repositories. Participants consented to participation in both survey completion and the recording of subsequent focus groups.

Focus groups lasted for two hours. Locations were geographically spaced and selected based on highway proximity to facilitate representation from urban, suburban, and rural areas. Qualitative descriptive design, using content analysis, was used to analyze data from two focus groups of nurses with experience serving on governing boards.

Participants and Sample
Nurses were identified using one state board of nursing licensure survey data that provided the email address of each nurse who indicated serving on a board at the time of licensure renewal. Inclusion criteria were: 1) licensure as a registered nurse; 2) experience serving on a governing board; 3) completion of the demographic survey; and 4) availability to attend one of the two focus groups. Twenty-two participants met inclusion criteria; 19 attended a focus group. Ten nurses participated in focus group A; nine participated in focus group B.

Data Collection Procedure
Participants were asked to rate the relevance of each item using a 4-point Likert-like response scale with 1 = not relevant and 4 = highly relevant. An item content validity index (I-CVI) was completed. Items with an individual score of 0.78 and above were considered to be excellent, indicating high participant agreement on item relevance. Items below 0.78 were initially treated as weaker items (Polit & Beck, 2006). Results of the I-CVI were used to structure the focus groups and are included in Table 1.

Table 1. Content Validity Index

	CVI Range	Number of Items	Combined CVI Average
Professional Experiences Item Repository
Excellent	0.78 - 1	70	0.917
Poor	0.25 - 0.77	16	0.602
Board Member Responsibilities Item Repository
Excellent	0.78 - 1	57	0.934
Poor	0.25 - 0.77	0	N/A

Participants took the researchers in an unanticipated direction by engaging in deep discourse about their experiences and board work...Following survey completion, two 2-hour focus groups were conducted to stimulate discussion and determine content relevance, item clarity, and construct representation and rationale to support initial item validity (Ryan, Gandha, Culbertson, & Carlson, 2014). Items with the lowest I-CVI scores were presented to participants first. The original intent of the focus group protocol was to target items with less agreement. However, all items were reviewed, regardless of the CVI, to provide clarifications and rationales for their ratings. Once this process began, focus group facilitators used probing questions to further clarify concepts, providing a deeper understanding of conceptual distinctions around items (Krueger & Casey, 2015). Participants took the researchers in an unanticipated direction by engaging in deep discourse about their experiences and board work, resulting in a rich discussion about which additional items were identified. These discussions proffered insights that extended the item repository.

Data Analysis
Inductive thematic analysis with open coding procedures was used to determine themes and subthemes (Elo & Kyngäs, 2008). Researchers reviewed the transcripts and identified topics and preliminary themes during the initial coding phase, which concluded when no new themes emerged (Charmaz, 2014). Second-level, focused coding was used to further define relevant themes. Themes generated from initial coding were used as a framework for this procedure (Averill, 2015). Strategies used to ensure trustworthiness of data and procedures included member checking, peer debriefing, audit trail and journaling (Cope, 2013; Creswell & Clark, 2011).

Findings

Participant demographic data is reported in Table 2. Five themes emerged from the data. These findings assisted in refining items for a researcher-developed repository.

Table 2. Demographics

Category	Group A (n = 10)	Group B (n = 9)
Age	58.3% were 46-65 years	87.5 % were 46-65 years
Gender	Female (100%)	Female (100%)
Race	White (90%) Other (10%)	White (87.5%) Black (12.5%)
Nursing Experience	16-56 years (M = 43)	16-50 years (M = 38)
Employment Position	Retired (40%) Administration (40%) Other (20%)	Retired (25%) CNS (25%) Staff RN (25%) Educator (12.5)
Number of Boards	1-6 (M = 3)	1-6 (M = 3)

Emerging Themes
Study themes and subthemes are identified in Table 3. Additional discussion is offered with supporting quotations.

Table 3. Themes and Subthemes

Theme Summary	Themes	Subthemes
Experiences and skills intertwine	Nursing is such an intrinsic part of the individual that experiences and skills are intricately entwined.	● Nursing Education ● Nursing Practice ● Relationships with Others
Foundational experiences support credibility	Some experiences were important for providing a foundation for board work, but others were important in establishing credibility for being invited onto boards.	● Specialty Certification ● Collaboration ● Credibility ● Networking
Transferable skills	Many experiences emerged that were identified as providing a foundation for transferable skills.	● Advocacy ● Assessment ● Budgeting and Finance ● Communication ● Critical Thinking ● Facilitation ● Ethics ● Multidisciplinary Communication ● Negotiation ● Research Experiences ● Strategic Planning ● Succession Planning
Use of policy processes	Understanding of the policy process and political skills were identified as important.	● Advocacy ● Agenda Setting ● Legislative Process ● Legislative Program ● Political Implications ● Policy Development Process ● Program Evaluation
Networking	Networking was a necessary experience that facilitated a board position and contributed to a deeper understanding of complex situations.	● Collaboration ● Leadership Development ● Multidisciplinary Networking ● Professional Networking ● Relationship with Stakeholders

Nurse participants described how being a nurse permeates everything they do.Experiences and Skills Intertwine. Nursing is such an intrinsic part of an individual that experiences and skills are intricately entwined. Nurse participants described how being a nurse permeates everything they do. Thus, they found it challenging to delineate nursing versus non-nursing skills and attributes. For example, one participant stated,

Well... a nurse, that’s who I am.… What do I bring just because I’m a nurse? I don’t know but the whole thing for me is kind of blurry and muddy because no matter where I go and no matter what I do, I’m a nurse.

Participants agreed that their experiences with nursing education, practice, and professional relationships contributed to skill development. However, they found it difficult to separate professional identity from experiences and skill sets. A second participant summarized the strength of her identification with nursing professional identity by stating,

We are nurses; that’s our foundation. No matter what we are doing, serving on a board at church, at school, or at a hospital, people know that we carry that credential and that education with us and the ethics, morals and the discipline that come with it.

Discussion of professional certification became pivotal. Foundational Experiences Support Credibility. Some experiences were important for providing a foundation for board work, but others were important in establishing credibility for being invited onto boards. Focus group discussions were intended to identify experiences that participants found useful in board work. Discussion of professional certification became pivotal. Many participants initially expressed that specialty certification had little relationship to board work, but a discussion of related items moved the groups to describe when certification could be helpful. This conversation resulted in the refinement of items related to certification. Participants described how professional certification could influence board member recruitment. One participant expressed,

I’ve been on a number of boards. I don’t know that certification was useful to me while on the board, but the credential is what other people look at, so credentials are relevant and perhaps critical to get on a board and to being seen as credible.

Experiences that lead to connections beyond one’s employment position were seen as serving a dual purpose. These experiences were identified as useful to provide the foundation for board work as well as helping to secure a board position. This idea was articulated as, “Do you have connections to [people or groups] that can give us money? Those are reasons people are chosen to be on boards and those experiences are necessary.”

Many skills extracted from experiences were transferable to board work. Transferable Skills. Many skills extracted from experiences were transferable to board work. Participants identified ethics, critical thinking, multidisciplinary communication, knowledge of finance, and strategic planning as professional experiences that are transferable to board duties. Participants varied in their identification of business acumen as a transferable skill set. All agreed these skills were important. One participant provided context for this discussion, stating, ”Nurses are managing multi-million dollar budgets.… They can sit at the table and participate in conversations about finance in addition to conversations about the clinical aspect.”

An important distinction about the word “skills” arose from this conversation. Some participants stated that the characterization of nursing “skills” was frequently associated with tasks such as inserting intravenous access lines and urinary catheters, and administering medications. However, other participants stated that they saw a distinct difference between “skills” and “tasks” associated with nursing. A participant responded, “Skills are more than tasks. Skills are broader, and I think nursing skills do transfer but the tasks that you are describing do not.” As such, skills were transferable because they were linked to critical thinking. Critical thinking is a foundational skill that can assist acquiring and practicing other skills, like complex problem solving, necessary for effective board member performance.

Nurses with board experience perceived themselves as being outcome-oriented. This idea was expressed by one participant who stated, “I would say, as nurses, by virtue of just being nurses, we are very outcome-focused, very evidence-based driven. Sometimes I find, on the boards, that I’m the one who drives the solutions.” Participants linked outcome orientation to the skill of strategic planning. This discussion around skills contributed to the addition of some items, and the revision of other items in the repository, to add clarity.

Use of Policy Processes. Understanding the policy process and having political experiences were identified as important. Focus group discussions initially centered on the importance of agenda setting and policy processes but quickly expanded to the importance of board members understanding advocacy, policy development processes, legislative processes, political implications, and program evaluation. This conversation resulted in the addition of experience-related items to encompass these topics.

Understanding the policy process and having political experiences were identified as important. Knowledge of the policy process was described by a participant as, “...important because that’s very transferrable to many boards whether it’s healthcare-related or not.” Another participant identified and described the significance of understanding the political system, noting,

It is important to have an understanding of the political system in which you are functioning… [The nurse who has experience with local politics] can speak from the perspective of a nurse, but with the understanding of the political arena, too. We do not often think about nurses being involved in the political system unless they are involved with professional organization work.

Networking. Networking was a necessary experience that facilitated a board position and contributed to a deeper understanding of complex situations. There was universal agreement among participants regarding the importance of networking. Participants did not support the need to differentiate the level at which networking occurred or the forum in which networking took place. One member shared, “I don’t think it matters if networking is within nursing or with other disciplines. If you know how to connect with other people, which is what networking is, does the site or the circumstances matter?”

There was universal agreement among participants regarding the importance of networking. Participants talked about how networking was important for making connections and forming relationships with stakeholders. These connections were important for being invited onto a board and for fostering relationships once on the board. Participants also described the need to have connections that can lead to financial support for the organization. As an example, a participant offered, “I’ve also been on a board of an arts organization. I can’t act, I can’t sing, but I have connections.” There was agreement that networking was important regardless of level or venue. Consensus of the focus groups resulted in revision of items related to networking.

Discussion

Findings of this study confirmed the relevance of specific initial items, and validated key board member responsibilities and experiences that support board performance. Further, information gleaned from the emerging themes will be helpful to refine preliminary items to measure nurses’ experiences and contributions. Nurses in this study found most of the items extracted from the literature as relevant to their work on a variety of governing boards. Some items that related to professional experiences were initially rated as not relevant by some participants, but discussions surrounding those items supported their continued inclusion for further development as relevant and clear. Because all items related to board member responsibilities were evaluated as relevant, these items received less discussion than the professional experience items.

Nurses in this study confirmed that experience with finance and policy processes are necessary to contribute at the board table. The literature describes the importance of nurses on boards and the limited opportunity to fill board seats with nurses. Nurses in this study confirmed that experience with finance and policy processes are necessary to contribute at the board table. While participants affirmed these skills as important, they also identified these as two areas in which nurse expertise is frequently lacking, or perceived as lacking, by others. This perception was consistent with the literature (Khoury et al., 2011; Mason et al., 2013). Participants also identified that these skills are not being sufficiently developed in nurses who work in direct care positions or in the community. This further contributes to the perception that nurses lack the necessary finance and policy skills to be effective board members.

Nurses are recognized as leaders in healthcare (Institute of Medicine, 2011), and development of leadership skills for all nurses is paramount to prepare them for board member responsibilities (Joseph & Huber, 2015). If nurses are to be prepared to lead at the board level, experiences for direct care and community nurses to develop financial and policy skills must be readily available.

Many professional organizations have started these efforts. For example, leadership competencies advocated by The American Organization of Nurse Executives (AONE) and American Organization for Nursing Leadership (AONL) support the development of communication, knowledge, leadership, professionalism, and business skills (ANE & AONL, 2015). Competencies, tool kits, and white papers as well as formal educational offerings have delineated expectations of nurse leaders.

What is missing from these options are conversations with nursing students about the value of board service...What is missing from these options are conversations with nursing students about the value of board service, the facilitation of skill development, and the recognition of opportunities to serve. This study supports the continued refinement of evidence-based materials for direct care nurses and integration of financial and policy topics into curricula for nurses at graduate and undergraduate levels. Opportunities to advance and utilize these skills must be supported by providing time for these nurses to participate in dedicated activities that develop financial and policy skills.

Focus group participants clarified that some skills, such as professional certifications and network development, were advantageous in successfully pursuing a board seat. They specifically identify the nurse credibility that is perceived of value by board leadership related to professional certifications and professional networks (Sundean & Polifron, 2016). These findings provide a deeper understanding of the preparation, expertise, credibility, and networking skills necessary.

Nurses offer unique perspectives about cost, quality, safety, and patient and family experiences. Nurses offer unique perspectives about cost, quality, safety, and patient and family experiences. They possess a wide range of transferable skills, offering them the potential to impact organizations through board work (Sundean et al., 2018). Participants confirmed and extended this knowledge by identifying the transferability of skills gained from experiences. Our findings are noteworthy as the importance of nurses driving evidence-based practice, integrating critical thinking, and providing for inclusive communication are presented throughout nursing literature but have not been specifically linked to skills required for leadership at the board table. This discussion brought to light the fact that nurses have difficulty articulating their specific disciplinary contributions. As such, the development of an instrument that can help nurses reflect on and articulate their contributions would be helpful to validate current nurse board membership and authenticate what nurse leaders bring to the table.

Limitations

...nurses have difficulty articulating their specific disciplinary contributions.The first limitation of this study was the email list used to recruit participants and to compose the focus groups. Access to our target population may have been affected by invalid, duplicate, or alternative email addresses, which may have hindered potential participant responses. Although the original list was reported to be a compilation of nurses who self-identified as serving on a board, we learned from some nurses that they actually served on committees or councils rather than governing boards and thus did not meet inclusion criteria.

A second limitation was the number of participants. Recruiting more participants may have yielded different findings. Finally, the focus groups were limited to two locations within one state, and composition of the groups lacked gender and race diversity because all participants were female and nearly all self-identified as white. The study design offered the opportunity for diversity through recruitment of nurses throughout the state; however, the sample did not reflect that diversity.

Implications for Practice

There is call for corporate and community boards to diversify membership. There is call for corporate and community boards to diversify membership. Leaders are seeking the best ways to prepare new board members (Hesketh, Sellwood-Taylor, & Mullen, 2020). Findings from this study offer many implications to assist both nurse and non-nurse board members to link professional experiences with board responsibilities. Specific implications include continued interdisciplinary refinement of evidence-based, board-readiness instruments for nurses; development of meaningful interprofessional education; and interdisciplinary mentorship that encourages nurses to communicate discipline-specific value statements that may assist non-nurse board members to identify positive contributions.

Conclusion

This exploratory phase of instrument development provides findings that validate potential instrument items. Our study adds to the body of knowledge regarding nursing presence on boards. Understanding how nurses see their experiences as board members and determining experiences that can be important for nurses seeking board positions will help them prepare for board roles. The information can also assist non-nursing colleagues to recognize how nurses impact governance. As the profession continues to move beyond the goal of 10,000 nurses on boards (NOBC, 2021), further study is needed to understand the unique disciplinary contributions of nurses to governing boards.

Authors

Yvonne M. Smith, PhD, APRN-CNS
Email: ysmith@bw.edu

AUTHOR:  Dr. Smith serves as Professor and Chair of the Nursing Department at Baldwin Wallace University. She has coordinated Nursing Administration and Dual MSN/MBA degree programs, where she re-designed curricula to include professional competencies and organizational, legal, and regulatory aspects of administrative practice. She has presented at national and international conferences on various topics and has held leadership positions, including Assistant Dean of Nursing Operations and President of the Ohio Board of Nursing. Dr. Smith is the primary investigator in studies of nurses serving on governing boards.

Kimberly A. Cleveland, JD, MSN, RN, C-MBC
Email: kthoma43@kent.edu

Cleveland is faculty/coordinator of healthcare policy at Kent State University College of Nursing. Cleveland has held multiple roles in healthcare administration, advanced nursing practice, law, and organizational governance. She is a published speaker, consultant, and educator. Cleveland is Chair-Elect for the Nurses on Boards Coalition (NOBC), on which she has served as representative of The American Association of Nurse Attorneys [TAANA].

Carolyn Kleman, PhD, MHA, RN, BCPA
Email: klemanc@uncw.edu

Dr. Kleman teaches and is coordinator of population health, finance, and policy in the nurse educator program at University of North Carolina Wilmington. Patient and nursing advocacy are her teaching, research, and service focus. She is currently investigating the work of managing a chronic illness and how self-advocacy skills are necessary for such work. Dr. Kleman has presented at regional, national, and international conferences on self-advocacy, mixed methods, and nurses on boards. She has been a founding member on a board for an addiction housing organization.

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