Michael Porter defined value as outcomes divided by cost1. Healthcare embraced the equation quickly but applied it unevenly. For decades, nurses have been treated primarily as a cost to be managed rather than as the people and capability that make outcomes possible. They are bundled into room charges, excluded from RVUs, and discussed more often as labor expense than as strategic assets. Yet nurses remain the largest segment of the healthcare workforce and the primary drivers of inpatient care, safety, and patient experience.2
For years, nurse leaders have asked how to assign value to nursing. The more urgent question today is simpler and more uncomfortable: how can healthcare be governed without nurses at the table?
Boards exist to steward trust, oversee risk, and ensure long-term viability. That responsibility becomes compromised when boards govern abstractions rather than the work itself. A healthcare board without nursing expertise is not balanced; it is incomplete. Most hospital and state healthcare association boards currently lack nurses as voting members of the board. Even when Chief Nursing Officers (CNOs) and Registered Nurse (RN) executives are present, formal governance power remains concentrated among Chief Executive Officers (CEOs) and other executive leaders. Representation without governing and voting authority creates an uneven table. The 2025 National Governance Report by the American Hospital Association states that the actual number of clinicians on hospital boards has decreased from 29% in 2014 to 26% in 2024. Physicians still make up most clinicians on hospital boards, but their proportion fell from 20% in 2014 to 16% in 2024. Nurses make up only 5% of clinicians on hospital boards and this is unchanged from 2014.3 This is not about representation. It is about whether governance reflects how care is actually delivered.
The breakdown becomes most visible around measurement. Leadership often says it wants better data on nursing. Nurses often resist being measured. The reason is not technical or ideological. It is trust. Trust that is visible and mutual.
Historically, healthcare made nurses’ work harder while removing the supports that once made the job doable. Unit clerks disappeared. Transport and ancillary roles thinned. Tasks that were never designed as nursing work were pushed onto nurses simply because someone had to absorb them. At the same time, patient acuity increased, technology proliferated, and documentation demands expanded relentlessly. Time-motion and EHR studies consistently show that nurses now spend roughly a third of their shift documenting care.4 That time does not replace patient care; it stacks on top of it.
This accumulation created a job that is no longer realistically finishable. The pandemic did not cause this. It exposed it.
In that context, resistance to measurement is rational. When visibility has historically preceded cuts rather than improvement, measurement feels like threat, not learning. The dominance of staffing ratios reflects this reality. Ratios are not what nurses want. They are the only measure nurses trust. They are blunt, incomplete, and insufficient—but they are defensible in a low-trust system. Ratios are not a solution; they are a symptom.
This is not a nursing failure or a leadership failure. It is a relationship failure, and therefore a governance failure. Measurement without trust is experienced as control. Measurement with trust becomes learning. And healthcare will not get better data, better workflows, or better outcomes until trust is addressed first.
That is precisely why nurses on boards matter.
As a nurse with more than four decades of experience across clinical care, administration, academia, and industry, I have focused this chapter of my career on bringing the nursing lens into governance. When I joined the Board of Directors at Children’s Mercy in Kansas City, MO, I was the only nurse and one of only a small number of clinicians. The response from nursing leaders was immediate. They did not experience it as symbolic. They experienced it as practical. For the first time, they believed decisions affecting their work would be shaped by someone who understood the realities they lived every day.
From the board side, the shift was equally tangible. Discussions about quality, safety, experience, and workforce sustainability became more grounded. Metrics were interrogated differently. Risks surfaced earlier. Strategy became more executable because it was anchored in how care actually happens, rather than how it is assumed to happen.
From a CEO perspective, this is not optional. Governing healthcare without nursing expertise is no longer defensible. A nurse on the board makes one governance question unavoidable: who was part of this decision? That question matters because the tradeoffs facing healthcare today are real and consequential. When nurses are part of governance, decisions become rounder and more credible. Consequences are anticipated rather than explained after the fact. And because nurses trust nurses, decisions shaped with nursing input land differently inside the organization.
The evidence supports what experience makes obvious. Higher patient-to-nurse ratios are associated with increased mortality, higher failure-to-rescue rates, and greater nurse burnout.5 Stronger nursing work environments are associated with better patient outcomes and improved retention.6 Missed nursing care is consistently linked to adverse outcomes.7,8 If boards care about outcomes, they must govern the conditions under which those outcomes are produced. One of the key tenets of high reliability is deference to expertise. Highly reliable organizations value expertise over authority and governance must reflect this principle.9
The important point is this: this is fixable. The AHA postulates that fewer clinicians on hospital boards may be the result of the difficulty in recruitment of clinical expertise outside of their own organizations.3 However, a large number of clinicians and nurse leaders specifically are in academia, self-employment, industry, and retirement. Perhaps recruitment needs to expand to these areas. But the first step is not a new metric, a new dashboard, or another performance initiative. The first step is trust. Trust is what allows transparency. Transparency allows learning. Learning allows redesign. Without trust, every attempt to “measure nursing better” will be interpreted as preparation for further extraction.
Boards helped create the conditions that made nursing work undoable. Boards therefore have a responsibility to help redesign it. That work cannot be done without nurses as full participants in governance.
This is now the baseline for competent healthcare governance.
References
Michael Porter and Elizabeth Olmsted Teisberg, Redefining Health Care (Massachusetts: Harvard University Press, 2006), 4.
American Association of Colleges of Nursing. Nursing Workforce Fact Sheet. 2024.
American Hospital Association (2025). 2025 National Governance Report
Bakhoum N, et al. Time and motion analysis of nurses’ EHR use.
Cho H, et al. Nurses’ documentation burden and workflow.
Aiken LH et al. Hospital nurse staffing and patient mortality, burnout, and job dissatisfaction. NEJM.
Lake ET et al. Nurse work environments and patient outcomes.
Nantsupawat A, et al. Missed nursing care and adverse outcomes.
“High Reliability,” Agency for Healthcare Research and Quality, updated July 2016,
The post The Value of Nurses on Boards Is No Longer Debatable appeared first on Becker's Hospital Review | Healthcare News & Analysis.
