The equation is simple, yet profoundly challenging for modern healthcare: value equals outcomes divided by cost. First articulated by Michael Porter and Elizabeth Olmsted Teisberg in their 2006 book, Redefining Health Care1, this framework has taken root, but its application remains uneven. For decades, nurses – the largest segment of the healthcare workforce and the primary drivers of inpatient care, safety, and patient experience2 – have often been treated as a cost to be managed, rather than as the essential capability that drives positive outcomes. This imbalance is now prompting a critical question: how can healthcare be effectively governed without the direct input of those providing the care?
The issue isn’t simply about representation, but about ensuring governance reflects the realities of care delivery. A growing body of evidence suggests that healthcare boards lacking nursing expertise are fundamentally incomplete. The 2025 National Governance Report by the American Hospital Association reveals a concerning trend: the proportion of clinicians on hospital boards has decreased from 29% in 2014 to 26% in 2024. Although physicians still comprise the majority of clinician representation, their numbers have also fallen, from 20% to 16% over the same period. Critically, nurses remain a negligible presence, accounting for only 5% of clinicians on these boards – a figure unchanged since 20143.
The Erosion of Trust and the Burden of Documentation
This lack of nursing representation stems from a deeper issue: a historical erosion of trust. For years, leadership has sought better data on nursing contributions, yet nurses often resist measurement, not due to ideological opposition, but because of a justified fear that data will be used to justify cuts rather than improvements. This dynamic has created a system where nurses are increasingly burdened with tasks outside their traditional scope of practice, as unit clerks and ancillary roles have been diminished. Simultaneously, patient acuity has risen, technology has proliferated, and documentation demands have exploded.
The result is a workload that is, realistically, unfinishable. Studies consistently show that nurses now spend roughly one-third of their shift documenting care4, adding to, rather than replacing, direct patient care. This accumulation of responsibilities, exacerbated by the pressures exposed during the COVID-19 pandemic, has led to a rational resistance to further measurement – a resistance born not of obstruction, but of a lack of faith in the system.
Governance as a Relationship, Not Just a Metric
This situation isn’t a failure of nursing or leadership, but a failure of the relationship between them, and a failure of governance. Measurement without trust feels like control; measurement *with* trust becomes a tool for learning and improvement. Until trust is addressed, any attempt to “measure nursing better” will be perceived as a prelude to further extraction of resources.
That’s why the presence of nurses on healthcare boards is no longer simply desirable, but essential. Michael Porter’s equation of value – outcomes divided by cost – underscores the need to understand the factors driving both sides of that equation. Nurses, as the primary drivers of inpatient care, possess invaluable insights into how to optimize outcomes and manage costs effectively.
A Shift in Perspective at Children’s Mercy
The impact of nursing representation on governance is tangible. When a nurse joins a board, it fundamentally shifts the conversation. At Children’s Mercy in Kansas City, Missouri, one nurse experienced this firsthand when becoming the only nurse and one of a modest number of clinicians on the Board of Directors. The response from nursing leaders was immediate and positive, as they felt their voices would finally be heard in decisions affecting their operate.
From the board’s perspective, discussions around quality, safety, patient experience, and workforce sustainability became more grounded in reality. Metrics were scrutinized more effectively, risks were identified earlier, and strategies became more executable because they were anchored in the actual delivery of care, rather than assumptions about it. This shift demonstrates that a nurse on the board prompts a crucial question: who was part of this decision?
The Evidence Supports a Change
The benefits of incorporating nursing expertise into healthcare governance are supported by a wealth of evidence. Research consistently demonstrates that higher patient-to-nurse ratios are associated with increased mortality, higher failure-to-rescue rates, and greater nurse burnout5. Conversely, stronger nursing work environments are linked to better patient outcomes and improved retention rates6. Missed nursing care, a direct consequence of inadequate staffing and support, is consistently associated with adverse patient outcomes7,8. Organizations prioritizing high reliability recognize the importance of deferring to expertise9, and governance structures must reflect this principle.
Addressing this imbalance is achievable. The American Hospital Association suggests that difficulty recruiting clinical expertise outside of traditional settings may contribute to the underrepresentation of clinicians on boards3. Expanding recruitment efforts to include clinicians in academia, self-employment, industry, and retirement could help address this challenge. However, the most crucial first step is rebuilding trust. Trust fosters transparency, which enables learning, and redesign of the system.
Healthcare boards helped create the conditions that made nursing work unsustainable. Now, they have a responsibility to help redesign it, and that work cannot be done without the full participation of nurses in governance. This is no longer a matter of best practice; We see the baseline for competent healthcare governance.
The path forward requires a commitment to fostering a culture of trust, transparency, and mutual respect between leadership and nursing staff. Only then can healthcare organizations truly optimize outcomes, manage costs effectively, and deliver the highest quality of care to their patients.
The American Hospital Association is expected to release updated governance data in early 2026, providing a further benchmark for progress. Readers are encouraged to share their experiences and perspectives on this critical issue in the comments below.
