Nursing Economic$
Board Culture and the Role of
Interpersonal Relations
Lisa J. Sundean
Board culture has significant
influence on board members’
decisions, effectiveness, and
overall organizational
performance. Board culture
develops from the quality of
relationships among board
members, as explained within
Peplau’s theory of interpersonal
relations. Nurse leaders who
understand and recognize the
characteristics of board culture
are ideally positioned to leverage
interpersonal relationships
among board members to
influence board deliberations and
decisions toward improved
health, health care, and health
equity for stakeholders.
Jacqueline Fawcett
“Culture is like the wind. It is
invisible; yet its effect can be
seen and felt” (Walker &
Soule, 2017, para. 1).
N urses are repeatedly
encouraged to prepare
for and operationalize
transformative leadership by
securing positions on boards of
directors (Nurses on Boards
Coalition [NOBC], 2020;
Sundean, 2020). Efforts to
advocate, prepare, and place
nurses on boards are directed
not only toward nurses and
nursing students but also toward
board leaders and organization
executives who are responsible
for board composition
(Cleveland & Harper, 2020;
Prybil, Popa, & Sundean, 2019;
Sundean et al., 2019). Despite
these efforts, nurses serving on
boards as a percentage of total
healthcare organization board
seats is static at about 4%
(American Hospital Association
[AHA], 2019; Prybil, 2016).
Considering advocacy initiatives
supporting board appointments
for nurses (Prybil, Popa,
Warshawsky et al., 2019), it is
surprising and of concern that
nurses serving on hospitals and
health system boards continue
to be limited. It is vital to
July/August 2021 | Volume 39 Number 4
Lawrence D. Prybil
continue the momentum to
increase board appointments for
nurses across sectors, parti-
cularly in the healthcare sector.
As nurses are encouraged to
prepare for and seek appoint-
ments on boards across sectors
(NOBC, 2020), we turn our
attention to the internal
environment of boards – board
culture – the environment board
members create collectively
through interpersonal
relationships (Walker & Soule,
2017).
Board culture, described as
a “pattern of beliefs, traditions,
and practices that prevail when
the board convenes to perform
its duties” (Prybil et al., 2012, p.
37), is a nuanced and essential
part of the board experience
that has substantial impact on
the adequate performance of
the board and organization
(BoardSource, 2017). Although
board culture is unseen, it is a
pervasive component of each
board (Walker & Soule, 2017)
and is regarded as central to
determining a board’s responses
to organizational needs and
external circumstances (Barlow,
2017; Howard-Grenville et al.,
2020). Understanding the
characteristics of board culture
and how it operates through
161

interpersonal relationships
among board members is
imperative for all board
members, including nurses
who serve on boards or aspire
to do so.
Considering the significance
of culture to board effectiveness
and organizational performance,
the purpose of this article is to
fill the gap in the nursing
literature by describing the
characteristics of board culture,
connect the significance and
operation of board culture
within the framework of
Peplau’s classic theory of
interpersonal relations (1952;
1997), and offer examples and
strategies for influencing board
culture to nurses who serve or
aspire to serve on boards. With
a clearer understanding of board
culture and how it operates,
nurses can leverage their
knowledge, perspectives, and
expertise to participate fully in
the work of boards.
Background
The genesis of this topic
was a presentation by the first
author (LS) about nurses’
influence on board effectiveness
and performance (Sundean,
2020). In preparation for the
presentation, an audit of the
nursing literature revealed a
dearth of literature about board
culture. An integrative review of
the state of the science about
nurses on boards from 1988 to
2015 revealed the acceleration
of nurses’ interest in board
service and called nurses to
action to serve on boards
(Sundean et al., 2017). Prybil
(2016) suggested barriers to
162
Nursing Economic$
nurses on boards are related to
gender disparities, lack of
appreciation of nurses’
qualifications for board
membership, and concerns
about conflicts of interest. These
barriers are supported by the
findings of meta-ethnography
revealing nurses and women on
boards face challenges including
lack of understanding by male-
dominated board leaders about
the credibility of board service
by nurses in particular and
women in general, cronyism,
tokenism, power struggles, and
perceived philanthropic
incapacity (Sundean & McGrath,
2016).
Other researchers have
explored experiences of nurses
on boards (Jones et al., 2016;
Murt et al., 2019; Sundean, 2017;
Sundean & McGrath, 2016;
Walton et al., 2015), nurses’
intentions to serve on boards
(Peltzer et al., 2015; Walton et
al., 2020), and the case for
nurses on boards (Sundean et
al., 2018). The extant body of
nursing literature demonstrates
increasing evidence supporting
nurses on boards and
momentum for board
preparation and placements.
However, a gap in the nursing
literature exists related to board
culture, its significance to board
effectiveness and organizational
performance, and interpersonal
relations in developing and
operationalizing board culture.
Characteristics of Board
Culture
The beliefs, traditions, and
practices reflected in board
culture develop from board
July/August 2021 | Volume 39 Number 4
members interacting to support
the organizational mission.
These features play a significant
role in deliberations, decision-
making, board effectiveness,
and organizational performance
(BoardSource, 2017; Daley et al.,
2018; Prybil et al., 2012).
Although the core characteristics
of board culture may vary from
board to board and may not be
uniformly represented within
each board, many traits overlap,
create conditions for other
characteristics, or result from the
activation of other attributes.
Eight generally agreed upon
traits of board culture are
described in Table 1 and
include (a) active engagement,
(b) openness to inquiry and
rigorous deliberations, (c)
cohesion and trust, (d) shared
commitment, (e) focus on
strategy and oversight, (f)
adherence to ethics and high
standards, (g) commitment to
broad diversity and expertise,
and (h) continual improvement
(BoardSource, 2017; Prybil et al.,
2009; Prybil et al., 2012).
Board Interpersonal
Relationships
The characteristics of board
culture are actualized through
the quality of interactions
among board members. Every
new board member enters into
an existing board culture, and
every new board member has
the opportunity to influence the
board’s culture. The primacy of
interpersonal relationships in the
development and
operationalization of board
culture has yet to be explicitly
acknowledged. Peplau’s (1952;
 Nursing Economic$

Table 1.
Characteristics and Descriptions of Board Culture

Characteristics of
Board Culture Description
Active engagement Board members are well informed, eager, and prepared for board meetings and deliberations
that lead to informed decision-making (Prybil et al., 2012). Board members are encouraged
to be informed on the operations of the organization but discouraged from “getting into the
weeds” of operations. Engaged board members are encouraged to ask probing questions
rather than tell the organization how to operate. Mission-focused rigorous deliberations are
one indicator of active board engagement (Braverman, 2019). Actively engaged boards tend
to be more aware of ethical hot spots within the organization and among board members
and are best positioned to address such concerns in a timely manner (Vollmer, 2018).

Openness to inquiry and Challenges to conventional thinking and dissent in decision-making are welcomed by the
rigorous deliberations board. The characteristic of board culture implies support for individual board members’
agency or voice including respect for dissent in decision-making (Creary et al., 2019;
Sundean & McGrath, 2016). The board’s openness to inquiry and rigorous deliberations
creates conditions for innovative problem solving, challenging conventional thinking, and
disrupting groupthink (AHA, 2019; Howard-Grenville et al., 2020).

Cohesion and trust The board develops a sense of unity among its members based on trusting relationships to
the extent that cohesion and trust are the mechanisms that draw diverse board members
together around shared purpose and organizational mission, supporting openness to inquiry
and rigorous deliberations (Foutty, 2020; Frei & Morriss, 2020; Prybil et al., 2012). Cohesive
boards collectively conform to meet organizational mission and generally agree on strategy
(Heemskerk et al., 2015) but are not so united that they fall into the trap of groupthink.

Shared commitment Collective commitment to the organization’s mission is paramount to the board’s culture
(BoardSource, 2017; Prybil et al., 2012). In the healthcare sector, the mission should focus
on high-quality care of the population served (Daley et al., 2018). Every board member has
an obligation to consider their alignment with the organization’s mission prior to joining the
board and must commit to working alongside fellow board members to advance the
mission. These considerations are part of the fit test – ensuring personal interests and values
align with the organization’s purpose (Curran, 2016).

Focus on strategy and Two main functions of boards are to define and approve organizational strategy, and then
oversight engage in actions to ensure the strategy is carried out to meet the mission (White & Griffith,
2019). The board whose culture is consistently attentive to strategy (the process for reaching
goals) and oversight functions also encourages active engagement and accountability for
decisions (Peisert, 2018). The board’s focus on strategy and oversight of organizational
performance creates conditions for the board to ask the right probing questions on behalf of
stakeholders (AHA, 2019; BoardSource, 2017).

Adherence to ethics and The board demonstrates collective commitment to ethical practices and high standards of
high standards governance, hallmarks of effective board governance (Vollmer, 2018; White & Griffith, 2019).
Accountability for decisions and oversight demonstrate high standards. Governance
practices founded on and guided by ethics and high standards maintain the reputation of
the organization and board (BoardSource, 2017).

continued on next page

July/August 2021 | Volume 39 Number 4 163

 Nursing Economic$

Table 1. (continued)
Characteristics and Descriptions of Board Culture

Characteristics of
Board Culture Description
Commitment to broad A significant component of board effectiveness is the broad diversity of its members and
diversity and expertise willingness to draw upon different experiences, perspectives, and expertise (BoardSource,
2017; Prybil, Popa, Warshawsky et al., 2019). Board composition inclusive of broad diversity
and expertise facilitates openness to inquiry and rigorous deliberations. Heterogeneous
boards harness the full brain trust and multiple perspectives of their members (Creary et al.,
2019; Foutty, 2020; Landaw, 2020).

Continual improvement Commitment to continual improvement facilitates development of board skills and leadership
capabilities relevant for carrying out board duties and ensures effective board culture is
maintained over time (Cleveland & Harper, 2020; Vollmer, 2018). Continual improvement
through education, development, and self-evaluations demonstrates the board’s
commitment to high standards (AHA, 2019; BoardSource, 2017).

1997) classic nursing theory of phases of interpersonal relations Orientation Phase

interpersonal relations was
selected as a sound theoretical
approach for understanding,
navigating, and contextualizing
board culture.
Although Peplau’s theory
focuses on the nurse-patient
relationship, the theory is
equally applicable to
interpersonal relationships
between other persons, such as
nurse and non-nurse board
members. According to Peplau
(1997), “Relations refers to the
connections, linkages, bonds, or
patterns that develop and are
identifiable in the relationship”
(p. 162). This explanation is
congruent with the definition of
board culture as described in
the seminal works of Prybil and
coauthors (2009; 2012).
Peplau’s theory of inter-
personal relations is divided into
three overlapping phases:
orientation, working, and
termination. The working phase
is further divided into two
subphases: identification and
exploitation. The theoretical
overlap with the characteristics
Combined with assessing
of board culture (see Table 2).
personal values, qualifications,
Application of Peplau’s Theory and expertise in alignment with
of Interpersonal Relations the organization’s mission, the
nurse leader enters the
The relational behaviors
orientation phase of
between board members
interpersonal relations before
collectively shape the board’s
formal installation onto the
culture and are directed toward
board. Assessment of the
achieving organizational goals
organization and its mission,
and mission. In the presence of
vision, values, and performance
interpersonal relations among
are a proxy for board culture
board members, the eight core
(Barlow, 2017). A strategy for
characteristics form a network
assessing board culture before
that is board culture.
joining a board is to engage as
Conversely, without
an external member of a board
interpersonal ties between board
committee. Boards are often
members, a healthy board
open to such arrangements, and
culture cannot develop.
this strategy can give a potential
According to Barlow (2017),
board member time to observe
unhealthy board culture is a
board dynamics and culture
major barrier to achieving
during committee meetings.
organizational goals.
Direct inquiry about board
Professional and social
culture during the interview
opportunities to build board
process with existing board
relationships provide fertile
members is appropriate for
ground to grow effective board
board candidates. An alternative
culture that achieves
to asking about board culture
organizational goals focused on
during the interview is to
mission.
discuss the board’s culture

164 July/August 2021 | Volume 39 Number 4

 Nursing Economic$

Table 2.
Phases of Peplau’s Theory of Interpersonal Relations and Application to Board Culture

Phase/Subphase of Peplau’s
Theory of Interpersonal
Relations (1952; 1997)
Orientation phase
Description
People learn what each
has to offer in the
relationship.
Application to Development and
Maintenance of Board Culture
New board member assesses existing board member
dynamics and organizational performance. Existing board
members also assess new board member’s fit for the
existing culture.

Working phase The work of the people in
the relationship occurs
and is further divided into
two sub-phases.
To carry out board duties on behalf of the organization,
board members engage in priority setting, strategic
planning, financial analysis, executive evaluations, and
board self-evaluations. Each board member leverages their
values, experiences, and relational abilities toward the
purpose of achieving organizational mission. Deliberations
and decision-making in the working phase of board
members’ relationships with each other (including both
subphases) demonstrate the board’s culture.

Identification subphase People learn how to Board members engage in discussions and deliberations
leverage the interpersonal that reveal their values and expectations about
relationship toward a organizational goals.
purpose.

Exploitation subphase People make full use of Board decisions that will advance organizational goals are
the interpersonal supported by the quality of the network of board culture
relationship during this characteristics.
subphase.

Termination phase
People end the Succession planning for planned or unplanned board
relationship. turnover either aims to maintain the existing board culture
or seeks to reshape board culture to a future state based
on a variety of factors. Formal succession planning relies
on communications among board members to determine
attributes of new board members, potential impact on the
board’s culture, and potential impact on the organization.
The board member who rolls off the board leaves a legacy
based on relationships with existing board members and
how those relationships resulted in a culture that
supported the organization’s mission.

privately with one or more
current board members to
understand better how work
gets done, how crises are
handled, how discussions
proceed, how decisions are
made, how board recruitment is
managed, and how the board
assesses its performance (AHA,
2019; Prybil et al., 2012). During
the orientation phase, the nurse
leader also assesses their
potential contributions to the
board’s culture.
Regardless of how the nurse
leader becomes oriented to the
board, they can ask probing
questions about the
characteristics of board culture
(see Table 1). These
conversations provide a
structured format for assessing
board culture. Further, the
orientation phase offers an
opportunity for existing board
members to determine the
board candidate’s fit with the
board culture and organization
mission.

July/August 2021 | Volume 39 Number 4 165

 Nursing Economic$

Working Phase and interpersonal relations is professional expertise and

required for boards to be promoted high standards and
Once formally installed on
effective. Nurses’ expertise in ethics among the board
the board, the nurse leader
interpersonal skills facilitates members to shift perspectives
transitions into the working
effective board discussions and and shape board culture
phase of interpersonal relations
deliberations (Sundean et al., centered on organizational
(inclusive of both subphases).
2018). mission. The board members
Interactions between board
Active engagement and trust reconsidered their strategy and
members signal how the board’s
between board members create contracted with a 24-hour in-
culture is operationalized,
conditions for candid house radiology group to ensure
maintained, and evolves.
discussions, respectful dissent, quality care. The nurse’s skill in
Continual attention to board
and decisions made from interpersonal relationships
culture through board members’
diverse perspectives fostered acceptance of her
relationships is crucial for board
(BoardSource, 2017; Frei & expressed concerns, providing a
effectiveness and organizational
Morriss, 2020; Prybil et al., template for centering the
goal achievement (Barlow,
2012). Board relationships discussion, deliberations, and
2017).
maintained with high standards, decision-making on patient care
The board experience of the
ethics, and focused on outcomes and organizational
first author is shared to illustrate
organizational goals can make a mission.
the importance of the quality of
difference in decisions that In many cases, nurses bring
interpersonal relations in the
affect patient outcomes diversity of perspectives to
working phase. During a
(McBride, 2017). This point is energize the board, strengthen
hospital board retreat, a
exemplified by another of the the board culture characteristic
consultant asked the board
first author’s board experiences. of cohesion, and advance the
group, “Do you all get along
A hospital on probation for organization’s goals (Prybil,
well?” The group nodded in
significant quality errors had Popa, Warshawsky et al., 2019;
agreement, proud of their
contracted with a company to Sundean et al., 2018). Although
collegiality. The consultant
provide 24-hour radiology culture change is slow, it is
continued, “Do you make
services. Over time, the quality worth the effort to ensure board
decisions fairly easily?” The
issues were corrected, and the governance is unified around
group nodded again, quite
hospital was removed from the needs of stakeholders
proud. “That’s terrible,” said the
probation. The board (Howard-Grenville et al., 2020;
consultant. “To carry out your
considered canceling the Walker & Soule, 2017).
board duties, you will need to
radiology service contract Consider the board
trust each other enough to
without replacing it with an experience of the first author,
challenge each other’s thinking
alternative contract to save who suggested the board quality
and perspectives to make the
money. Although most board committee oversee the hospital’s
best decisions on behalf of the
members agreed with this community benefits plan and
organization. Board decision-
approach, the nurse asked how community health needs
making is not an easy process.”
the hospital would ensure assessment in compliance with
Although general collegiality
quality care for patients without Internal Revenue Service
among board members is
24-hour radiology services. regulations. Board members
desirable, cohesion and trust
Further, the nurse board were not well versed in the
must pave the way for rigorous
leader asked if the board was policy and regulation and
deliberations based on high
ready to potentially manage the expressed no need to take on
standards, ethics, and shared
cost of a similar quality crisis if the oversight. The nurse began
commitment to the organization
the radiology service contract educating the board about
(Frei & Morriss, 2020; Vollmer,
was not maintained or replaced. community benefits policy and
2018). This level of engagement
The nurse leveraged health needs assessment

166 July/August 2021 | Volume 39 Number 4


regulations. After 3 years and
persistent effort from the nurse
board leader, the board
committee finally recognized the
need to oversee the community
benefits and health needs
assessment plan. The nurse
board member’s expertise,
communications, education, and
persistence helped shape the
culture from one that dismissed
community needs and benefits
to embrace continual
improvement in understanding
population health issues. The
nurse board member’s relational
skills unified the board around
common purpose as explicated
in Peplau’s (1952; 1997) claims
about interpersonal relations
and core characteristics of board
culture (BoardSource, 2017;
Prybil et al., 2009; Prybil et al.,
2012).
The quality of interpersonal
relations among board
members, based on cohesion
and trust, is integral to the
group’s openness to inquiry and
rigorous deliberations, as
evidenced in the previous
example. Respect for diversity of
thought and perspectives among
board members creates
conditions for more effective
decision-making (Foutty, 2020;
Prybil, Popa, Warshawsky et al.,
2019). The first author shares an
example of a board that was
deliberating on expanding and
moving the hospital from an
existing urban location to a
suburban area. The board was
generally in favor of the
expansion and move, arguing it
would increase service line
offerings, market share, and
revenue. However, two board
members, a nurse and an
Nursing Economic$
educator, argued that such a
move would create a barrier to
healthcare access for the
organization’s target population.
The argument shifted the
thinking of the board. A
compromise was reached with
satellite clinics expanding in the
suburbs and the primary
hospital building remaining in
its urban location. The strength
of relationships among board
members and shared
commitment to the
organizational goals allowed
diverse perspectives to shape
the deliberations and decision-
making. The two board
members (nurse and educator),
with effective communication
skills and knowledge-based
understanding of the needs of
the target population, effectively
navigated the board culture and
unified the board’s decision
around access to care.
Attention to continual board
improvement, another core
characteristic of board culture
(Prybil et al., 2009; Prybil et al.,
2012), is evident throughout the
working phase of interpersonal
relations (Peplau, 1952; 1997).
Effective boards engage in
opportunities for learning and
improving board practices,
including their cultural patterns
(BoardSource, 2017). One
approach to improvement is
through regular board self-
evaluations to identify strengths,
weaknesses, and opportunities
for improvement (AHA, 2019).
The board’s culture, evident
through its internal discussions,
deliberations, and decisions, is
also apparent in its commitment
to developing its members
around best practices in board
July/August 2021 | Volume 39 Number 4
governance and response to
current issues relevant to
organizational mission.
Boards must ensure they
practice and support social
justice through board self-
evaluations, introspection, and
education. Especially in recent
years, many boards and
organizations are engaging in
such reflections and education
to shift oppressive structures to
be more inclusive and
emancipatory for all associated
with the organizations, from
board members to employees,
executives, and consumers
(Thomas-Breitfeld & Kunreuther,
2017). The work of social justice
is reflected in the relational
dynamics of board members
throughout all three phases of
Peplau’s theory of interpersonal
relations, from electing and
orienting new members to
enacting the values of board
members in the priorities,
strategies, and decisions made
on behalf of the organization.
Termination Phase
Board culture and impact on
working relationships among
board members extends into
board succession planning
which signals the termination
phase of Peplau’s theory of
interpersonal relations.
Succession planning is an
essential process in ensuring
board culture, through new
board membership, reflects
current knowledge, expertise,
and diversity to support the
organization’s mission (Prybil &
Gage, 2020). How the board’s
membership is comprised over
time is as much a factor of its
culture as regular meetings,
167
 Nursing Economic$

Figure 1.
Schema of Peplau’s Phases of Interpersonal Relations Applied to Board Culture

Board culture develops from the pattern of relationships among members and is comprised of eight core characteristics:

(1) Active engagement, (2) Openness to inquiry and rigorous deliberations, (3) Cohesion and trust, (4) Shared commitment, (5)
Focus on strategy and oversight, (6) Adherence to ethics and high standards, (7) Commitment to broad diversity and expertise,
(8) Continual improvement

Board culture is integral to the board’s effectiveness and organizational performance within the three overlapping phases of Board
Peplau’s (1952; 1997) theory of interpersonal relations.
Effectiveness
Orientation Phase Termination Phase and Organizational
Working Phase
Performance
• New board members enter the • Board members pass along and
existing board culture. • Board members create, maintain, reshape the board’s culture
• New board members assess the and shape the board’s culture through through succession planning.
board’s culture through discussions, deliberations, decision- • Each board member leaves a
organizational performance and making, and self-evaluations. cultural legacy when their board
board dynamics. tenure is over.

deliberations, and decision- expertise, nurses are well organization and its
making (BoardSource, 2019). positioned to develop and stakeholders. Ongoing board
Adherence to board term limits facilitate relationships among evaluations in the context of
demonstrates ethical governance board members that are interpersonal relationships
practices, high standards, and necessary for effective among board members offer
continual board improvement governance and organizational opportunities to strengthen the
(BoardSource, 2019; Prybil, performance. By engaging in board’s culture in response to
Popa, Warshawsky et al., 2019). relationships to influence and organizational needs and current
maintain the board’s culture, the circumstances. Formal
Discussion and nurse board leader leaves a examination of board culture
Recommendations lasting legacy of effective through research is
governance and organizational recommended to better
The work of creating a performance (see Figure 1). understand board culture’s
strong, responsive, and inclusive For nurses interested in impact on organizational
board culture that supports the board service, attention to board performance.
organization’s mission, vision, culture is a critical component For example, a finding from
and goals is built upon the of assessing personal fit for the a study about board governance
foundations of interpersonal board. Similarly, attention to in high, medium, and low-
relationships. Through their developing and ensuring performing academic medical
professional and ethical interpersonal relationships centers in the United States
commitment to society among board members supports revealed an association between
(American Nurses Association, the rigor needed for the board nurses serving on boards and
2015) and professional to carry out its duties to the high-performing centers

168 July/August 2021 | Volume 39 Number 4


(Szekendi et al., 2015). This
finding warrants further
investigation to discern better
the contributions of nurse board
leaders to organizational
performance metrics and the
role of nurse board leaders’
interpersonal skills.
To support all nurses
interested in board service,
nurses should engage in
governance competency self-
assessment and preparation
(Harper & Benson, 2020;
Sundean, 2017). Nurses already
serving on boards should
advocate for regular board self-
assessments as a means of
supporting continual
improvement. Board succession
planning, part of continual
improvement, must focus on
diversity of overall board
composition to promote equity
and foster diverse perspectives
(Prybil & Gage, 2020). Nurse
leaders should assess their
understanding of the role of
interpersonal relations among
board members, operation of
board culture, and core
characteristics of board culture
related to board effectiveness
and organization performance.
Inclusion of governance
education across the nursing
curriculum to prepare nurses for
board leadership is advocated in
the nursing literature (Sundean
et al., 2019; Thomas et al.,
2017). Nurse educators should
inform about the importance of
board culture in shaping board
decisions and organizational
strategies, particularly
concerning population health
and social justice.
Nursing Economic$
Conclusion
Interpersonal relationships
among board members create
the board’s culture and
permeate every meeting, all
deliberations, and are a
substantial component of
effective governance
(BoardSource, 2020). Although it
may be challenging to prepare
for board culture, a clear
understanding of its
characteristics helps nurses
anticipate and recognize these
critical dynamics and patterns of
interactions among board
members. Peplau’s (1952; 1997)
theory of interpersonal relations
offers contemporary utility to
contextualize how board
member relationships operate to
create board culture.
The qualities of nurse leaders
– especially their interpersonal
skills – likely contribute to
healthy board culture. When
considering board service or
when serving on a board, nurse
leaders who understand and
recognize characteristics of board
culture are best positioned to
develop and leverage
interpersonal relationships
among board members to
influence board deliberations and
decisions toward improved
health, health care, and health
equity for stakeholders. $
Lisa J. Sundean, PhD, MHA, RN
Assistant Professor
University of Massachusetts Boston
Department of Nursing
Boston, MA
Jacqueline Fawcett, PhD, RN, ScD(hon),
FAAN, ANEF
Professor
University of Massachusetts Boston
Department of Nursing
Boston, MA
July/August 2021 | Volume 39 Number 4
Lawrence D. Prybil, PhD, LFACHE
Community Professor
University of Kentucky College of Public
Health
Lexington, KY
References
American Hospital Association (AHA). (2019).
National health care governance survey
report. https://trustees.aha.org/aha-
2019-national-health-care-governance-
survey-report
American Nurses Association. (2015). Code of
ethics for nurses with interpretive
statements. https://www.nursingworld.
org/coe-view-only
Barlow, J. (2017). Developing a healthy board
culture of corporate governance.
BoardEffect. https://www.boardeffect.
com/blog/developing-healthy-board-
culture-corporate-governance/
BoardSource. (2017). Leading with intent:
2017 national index of nonprofit board
practices. https://leadingwithintent.org/
wp-content/uploads/2017/11/LWI-
2017.pdf?
BoardSource. (2020). Culture and dynamics.
https://boardsource.org/fundamental-
topics-of-nonprofit-board-service/culture-
dynamics/
Braverman, B. (2019, Third Quarter). Culture
of inclusion: The board’s role in fostering
companywide diversity. Directors and
Boards, 44-46.
Cleveland, K.A., & Harper, K.J. (2020). Prepare
and pursue board opportunities: A
practical guide for nurse leaders to serve
on a board. Nursing Economic$, 38(2),
94-97.
Creary, S.J., McDonnell, M.H., Ghai, S., &
Scruggs, J. (2019). When and why
diversity improves your board’s
performance. Harvard Business Review.
https://hbr.org/2019/03/when-and-why-
diversity-improves-your-boards-
performance
Curran, C. (2016). Nurses on board: Planning
your path to the boardroom. Sigma
Theta Tau International.
Daley, U.E., Gandhi, T.K., Mate, K., Wittington,
J., Renton, M., & Huebner, J. (2018).
Framework for effective board
governance of health system quality.
Institute for Healthcare Improvement.
http://www.ihi.org/resources/Pages/IHIW
hitePapers/Framework-Effective-Board-
Governance-Health-System-Quality.aspx
Foutty, J. (2020, March/April). How to create
a board culture of inclusion. NACD
Directorship, 69.
169

Frei, F.X., & Morriss, A. (2020). Begin with
trust: The first step to becoming a
genuinely empowering leader. Harvard
Business Review, 98(3), 112-121.
Harper, K.J., & Benson, L.S. (2020). Are you
ready for board service? Identifying key
competencies and discovering your
path to the boardroom. Nursing
Economic$, 38(6), 316-323.
Heemskerk, K., Heemskerk, E.M., & Wats,
M. (2015). Behavioral determinants of
nonprofit board leadership: The case of
supervisory boards in Dutch secondary
education. Nonprofit Management &
Leadership, 25(4), 417-430.
Howard-Grenville, J., Lahneman, B., & Pek,
S. (2020). Organizational culture as a
tool for change. Stanford Social
Innovation Review, 18(3), 28-33.
Jones, A., Lankshear, A., & Kelly, D. (2016).
Giving voice to quality and safety
matters at board level: A qualitative
study of the experiences of executive
nurses working in England and Wales.
International Journal of Nursing Studies,
59, 169-176.
Landaw, J.L. (2020). How diverse is your
board, really? Harvard Business Review.
https://hbr.org/2020/06/how-diverse-is-
your-board-really
McBride, A.B. (2017). Serving on a hospital
board: A case study. Nursing Outlook,
65(4), 372-379.
Murt, M.F., Krouse, A.M., Baumberger-Henry,
M.L., & Drayton-Brooks, S.M. (2019).
Nurses at the table: A naturalistic inquiry
of nurses on governing boards. Nursing
Forum, 54(4), 575-581.
Nurses on Boards Coalition (NOBC). (2020).
About. https://www.nursesonboards
coalition.org/
Peisert, K. (2018). Setting goals for board
structure and culture: Preparing for
value-based care delivery. Healthcare
Executive, 72-75.
Peltzer, J.N., Ford, D.J., Qiuhua, S.,
Fischgrund, A., Teel, C.S., Pierce, J., …
Waldon, T. (2015). Exploring leadership
roles, goals, and barriers among
Kansas registered nurses: A descriptive
cross-sectional study. Nursing Outlook,
63(2), 117-123.
Peplau, H.E. (1952). Interpersonal relations in
nursing. A conceptual frame of
reference for psychodynamic nursing.
G.P. Putnam and Sons. Reprinted
1991. Springer.
Peplau, H.E. (1997). Peplau’s theory of
interpersonal relations. Nursing Science
Quarterly, 10(4), 162-167.
Prybil, L.D. (2016). Nursing engagement in
governing health care organizations:
Past, present, and future. Journal of
Nursing Care Quality, 31(4), 299-303.
170
Nursing Economic$
Prybil, L.D., & Gage, L.S. (2020). Best
practices in board succession planning.
Boardroom Press, 31(5), 1-4.
Prybil, L.D., Levey, S., Killian, R., Fardo, D.,
Chait, R., Bardach, D.R., & Roach, W.
(2012). Governance in large nonprofit
health systems: Current profile and
emerging patterns. Commonwealth
Center for Governance Studies, Inc.
Prybil, L.D., Levey, S., Peterson, R., Heinrich,
D., Brezinski, P., Zamba, G., … Roach,
W. (2009). Governance in high-
performing community health systems:
A report on trustee and CEO views.
Grant Thornton, LLP. https://trustees.
aha.org/sites/default/files/trustees/
2009-prybil-report.pdf
Prybil, L.D., Popa, G., & Sundean, L. (2019).
Involving nurse leaders in governance
roles. Boardroom Press, 30(4), 4, 14.
Prybil, L.D., Popa, G.J., Warshawsky, N.E., &
Sundean, L.J. (2019). Building the case
for including nurse leaders on
healthcare organization boards. Nursing
Economic$, 37(4), 169-177, 197.
Sundean, L.J. (2017). Healthcare board
competency survey for nurses:
Assessing board readiness. Nursing
Economic$, 35(6), 295-303.
Sundean, L.J. (2020). Board cohesiveness,
culture of inquiry & disruption: A fine
balance. Connecticut Nurses
Association.
Sundean, L.J., & McGrath, J.M. (2016). A
metasynthesis exploring nurses and
women on governing boards. Journal of
Nursing Administration, 46(9), 455-461.
Sundean, L.J., Polifroni, E.C., Libal, K., &
McGrath, J.M. (2017). Nurses on health
care governing boards: An integrative
review. Nursing Outlook, 65(4), 361-
371.
Sundean, L.J., Polifroni, E.C., Libal, K., &
McGrath, J.M. (2018). The rationale for
nurses on boards in the voices of
nurses who serve. Nursing Outlook,
66(3), 222-232.
July/August 2021 | Volume 39 Number 4
Sundean, L.J., White, K.R., Thompson, L.S.,
& Prybil, L.D. (2019). Governance
education for nurses: Preparing nurses
for the future. Journal of Professional
Nursing, 35(5), 346-352.
Szekendi, M., Prybil, L., Cohen, D.L.,
Godsey, B., Fardo, D.W., & Cerese, J.
(2015). Governance practices and
performance in US academic medical
centers. American Journal of Medical
Quality, 30(6), 520-525.
Thomas, P., Servello, D., & Williams, J.
(2017). Baccalaureate education: The
foundation for healthcare board
participation. Nursing Forum, 52(4),
289-297.
Thomas-Breitfeld, S., & Kunreuther, F. (2017).
Race to lead: Confronting the nonprofit
racial leadership gap. Building
Movement Project. https://building
movement.org/wp-content/uploads/
2019/08/Race-to-Lead-Confronting-
the-Nonprofit-Racial-Leadership-
Gap.pdf
Vollmer, S. (2018). The board’s role in
promoting an ethical culture. Journal of
Accountancy, 226(1), 79-83.
Walker, B., & Soule, S.A. (2017). Changing
company culture requires a movement,
not a mandate. Harvard Business
Review. https://hbr.org/2017/06/
changing-company-culture-requires-a-
movement-not-a-mandate
Walton, A., Lake, D., Mullinix, C., Allen, D., &
Mooney, K. (2015). Enabling nurses to
lead change: The orientation
experiences of nurses to boards.
Nursing Outlook, 63(2), 110-116.
Walton, A.L., McLennan, D., & Mullinix, C.F.
(2020). Encouragement: The key to
increasing the number of nurses on
boards. Nursing Forum, 55(3), 331-340.
White, K.R., & Griffith, J.R. (2019). The well-
managed healthcare organization (9th
ed.). Health Administration Press.
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