Designing A Shared Governance Model: Soaring To New Heights
Designing A Shared Governance Model: Soaring To New Heights
Berthenya Dunbar, ARNP, MSN, BC; Diane Mayes, MSN, RN, CCRN; Bonnie Park, RN, BSN, CPAN; Rosemary Ashby, MS, ARNP-C; Mary Berger-Wesley, RN, MSN; Terri Cameron, RN, BSN ; Barbara T. Lorenz, ARNP-BC; and Magaret Veneman,BSN, RN, CRRN, CBIS.
Shared governance nursing models were introduced as a vehicle to improve nurses’ satisfaction, retention, and perception of their work environment (Anthony, 2004). Porter-O’Grady (2001), a pioneer in the field, reports nursing shared governance models have been in practice for over 20 years. Between 1986 and 1998, however, Aiken, Clark, & Sloane (2000) found nurses’ perceptions of their freedom to participate in important decisions about patient care and their work had decreased from 98% to 80%. Of equal concern, nurses believed their control over their nursing practice decreased from 92% to 56%. A new nursing shortage (Hess, 2004), the approaching retirement of “baby boomer” nurses ( Batson, 2004), and emerging data indicating that nurses desire some control over their practice (Kramer & Schmalenberg, 2003), has generated a renewed interest in shared governance.
Batson (2004) reports shared governance is a collaborative effort. When decision making is shared, accountability and responsibility is shared. Shared governance empowers nurses to challenge the status quo and to become proactive in their practice of nursing (Doherty & Hope, 2000).
This article will outline the steps taken to design a shared governance model in the first Magnet designated Veterans’ Hospital and its outlying clinics.
The Design Team
The nurse executive at the James A. Haley VA Medical Center (JAHVAMC) located in Tampa, Florida chartered a team and called for volunteers to research, design and recommend a shared governance model for nursing service. Members selected for this design team represented every nursing level and every area of nursing practice in the hospital. Representatives from both collective bargaining units were also invited to join the team. Members of the design team knew the concepts of shared governance were desirable. It was quickly decided, however, that the group needed additional education. There were many questions to answer: What, exactly, did the concept of shared governance entail? What was in the shared governance literature? How would shared governance be integrated within the unique structure of a VA Medical Center? What designs were already available and what were the advantages and disadvantages of each? How would current committees be incorporated into a shared governance model? What shared governance structures existed in the immediate hospital community?
The larger group was divided into subgroups to review the literature and model designs, the existing committee structure, and shared governance structures in the community. Additionally, a timeline and work plan was created that included all the work to be accomplished by the design team including implementation and evaluation. Subgroups reported back to the larger group.
Model Development
Hess (2004) suggests structure is critical to shared governance. He describes three models that appear most often in shared governance literature. With the Councilor Model, decisions are made in councils of managers and staff nurses. In the Administrative Model, the organization is divided into either a clinical or management focus. The Congressional Model includes all staff as members and the work is done by members who belong to cabinets. Unit-based shared governance is another model that is widely used. The Unit-based model permits each unit to develop its own system of shared governance. When used alone, however, the Unit-based system does not afford an opportunity for sharing with other units throughout the hospital (Scott & Caress, 2005). When exploring models within the community, one unit in a facility had a strong shared governance base. In 5 years, however, shared governance had not spread to other units within that facility!
The Councilor and Unit-based models were chosen to meet the needs of the JAHVAMC. The two-tiered structure permits staff on all levels to be involved in shared governance-either at the unit or council level. Existing committees were categorized and assigned to groups. The process provided the appropriate names and work for the proposed councils. The four resulting councils are Practice, Professional Development, Advocacy, and Quality. A Coordinating Council was added to the design to provide linkage and oversight for the four hospital councils and for unit-based councils. The hospital was divided into seven practice areas by grouping units of similar practices together. For example, Practice Area 1 is made up of all medical surgical units. Practice Area 2 is made up of intensive care and operative services.
The two-tiered model also permits the formation of forums. Forums are groups that meet primarily for education, support, and communication. This model provides for three forums- research, advanced practice nursing, and nurse managers. Forums are created or dissolved through the Coordinating Council.
The Councils: Purpose and Membership Structure
The Coordinating Council is chaired by the nurse executive. To maintain the integrity of staff nurse involvement, only staff nurses serve as chairs of the other four councils. Each council has a professional advisor who is an expert in the area of practice the council represents. For an example, the Quality Council’s professional adviser is the Associate Chief of Nursing for Quality Improvement and the professional advisor for the Advocacy Council is the Director of Nursing for Staff Relations. Council membership is through election from the practice areas; professional advisors are position driven. There is also union representation on the councils. Each of the seven practice areas has a representative at each meeting. Meetings are held at least monthly, and more frequently as needed. Councils receive their work from the overall nursing service strategic plan and from Council Action Requests. A Council Action Request is a form that permits a unit, a group, or an individual to request a particular council to consider a specific proposal.
Each council has a specific purpose. The Coordinating Council provides direction, communication and linkage to the other four councils. The Practice Council defines, implements, and maintains standards of clinical practice while setting the criteria for evidence-based practice. The Professional Development Council oversees the development and implementation of programs that support competency, academic endeavors, and professional development of nursing staff. The Quality Council monitors and evaluates performance and outcome measurements based on evidence-based practice and research. The Advocacy Council provides a forum for nursing staff to proactively address issues that make an impact on nursing satisfaction, recruitment, retention, and recognition.
The Unit-Based Model
To help units engage in Unit-based shared governance, the design team created the role of the Unit-based facilitator. The Unit-based facilitator is a member of a unit whose responsibilities include helping units coordinate their meetings and unit-based activities. Each unit decides how the role will be filled. The facilitator’s responsibilities include filing a quarterly report to the Professional Development Council. The quarterly report helps the Professional Development Council identify the successes and challenges of a particular unit. The Professional Development Council reports unit findings and actions to the Coordinating Council in its quarterly report. The quarterly reporting is a communication link that eliminates the problem of isolation identified by Scott and Caress (2005).
Bylaws
Though shared governance promotes nursing empowerment and pro-activity, the design team determined the mission statement of this institution’s shared governance structure would reflect the goal of developing and maintaining a structure that is patient-centered. The mission statement reflects the goals of this institution’s nursing service-high quality care, that is cost-effective, safe, timely, efficient, equitable, comprehensive, compassionate, ethical, and patient-centered (James A. Haley Nursing Service Shared Governance Bylaws, 2005). The bylaws define the structure and membership guidelines of the councils, details council duties, and explains the elections process.
Readiness Plan
Scott and Caress (2005) stress the fact that implementation is not an overnight venture. Kennerly (2000) reports education and communication are vital to the process of transitioning. The design team took these issues into consideration. The hospital was divided into small educational work groups to give all staff an opportunity to aid in the final design structure. The small groups were interdisciplinary, including key human resource personnel and members of the hospital’s executive board. A self study booklet was created early in the process and an Intranet Web site was set up to aid in the communication process. The first councils were staffed with volunteers. Subsequent council members were elected. The readiness plan included three phases: council set-up and education, hospital awareness and unit-based set-up, and the initial implementation program title: Soaring to New Heights.
JAHVAMC and its outlying clinics is a large and highly structured organizational system. Such a system presented a true design challenge. The design group used all available resources and 2 years to develop a shared governance structure based on current literature, the best of what the community had to offer, interdisciplinary staff input, and organizational need
References
Aiken, L., Clark, S., & Sloane, D. (2000). Hospital restructuring: Does it adversely affect care and outcomes? Journal of Nursing Administration 30(10): 457-465
Anthony, M. K. (2004) Shared governance models:
The theory, practice, and evidence.
Online Journal of Issues in Nursing 59(1), retrieved February 9, 2004 from www.nursingworld.org/ojin/topic23/tpc23_4.htm.
Batson, V., (2004) Shared governance in an integrated health care network. AORN Journal (Association of Operating Room Nurses), 80(3). 494-509
Doherty, C. & Hope, W. (2000) Shared governance–Nurses making a difference. Journal of Nursing Management 8, 77-81.
Hess, R. G. (2004) From bedside to boardroom:
Nursing shared governance.
Online Journal of Issues in Nursing, 9(1). Retrieved November 22, 2004 from www.nursingworld.org/ojin/topic23/tpc23_1.htm.
James A Haley Veterans Hospital Nursing Service Shared Governance Bylaws (2005) Mission Statement, July 6, 3.
Kennerly, S. (2000) Perceived worker autonomy: The foundation for shared governance. Journal of Nursing Administration 30(12) 611-617.
Kramer, M. & Schmalenberg, C. E. (2003) Magnet hospital nurses describe control over nursing practice. Western Journal of Nursing Research, 25(4), 424-452.
Porter O’Grady, T. (2001). Is shared governance still relevant? Journal of Nursing Administration, 31(10), 468-473.
Scott, L. & Caress, A. (2005) Shared governance and shared leadership: Meeting the challenges of implementation. Journal of Nursing Management, 13, 4-12.
All authors are with the James A. Haley VAMC in Tampa, Florida. Berthenya Dunbar, ARNP, MSN, BC, is a mental health nurse liaison; Diane Mayes, MSN, RN, CCRN, is a clinical educator; Bonnie Park, RN, BSN, CPAN, is a staff nurse; Rosemary Ashby, MS, ARNP-C, is a gastroenterology specialist; Mary Berger-Wesley, RN, MSN, is a geriatric clinic coordinator; Terri Cameron, RN, BSN, is an assistant nurse manager; Barbara T. Lorenz, ARNP-BC, is a cardiothoracic nurse practitioner; and Magaret Veneman,BSN, RN, CRRN, CBIS, is a nurse manager, rehabilitation.
Laureen Doloresco, MN, RN, CNAA-BC, associate chief of nursing, Haley VA Medical Center, Tampa, Florida and editor of the Leadership Circle column, welcomes your comments, questions and suggestions; contact her at laureen.doloresco@med.va.gov.