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Taking control through shared governance

Monday September 9, 2013
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The typical healthcare organization’s administrative team often includes a nurse leader who has the ultimate decision-making power for nursing processes. In the shared-governance model, however, decisions of consequence are made by teams that include staff nurses whose experiences can testify to which processes are working and which can use an overhaul. The model is a challenge to establish, but many experts say it’s well worth the effort.

Shared-governance models in nursing rely on self-managed, decentralized teams that solve problems and make decisions that affect patients and nurses. At its most basic, teams focus on issues such as self-scheduling, revising the peer review process or introducing new equipment. As it develops within an organization, shared governance tends to become more interdepartmental, solving broad-range issues with patients and the delivery of care in mind, said Susie Allen, RN-BC, MSN, assistant vice president for professional excellence at Cincinnati Children’s Hospital.

“Shared governance is just a leadership learning lab to understand what it takes to make an organization run and what nursing’s role should be in an organization,” Allen said. “It’s also about discovering the power of nursing.”


Robert Hess, RN
The model takes into account control over nursing practice, said Robert Hess Jr., RN, PhD, FAAN, executive vice president for global programming at Gannett Healthcare Group and founder of the Forum for Shared Governance. “It’s a professional organizational model in which staff nurses also have legitimate influence over some areas traditionally controlled by management only,” he said.

Hess said shared governance was initially a radical break from the traditional hierarchical management model.

A 30-year-old concept

Participative management, first discussed in business and management literature in the 1970s, was adapted by healthcare organizations and nursing leaders in the early 1980s.

Today, shared governance in nursing has evolved to not only resolve issues related to patient care, but also to help define the practice of nursing within the organization, experts say. The concept is gaining traction; the American Nurses Credentialing Center now requires that a shared governance system or similar structure that supports shared leadership and participative decision-making and promotes nursing autonomy is in place at a healthcare organization as a prerequisite to seeking Magnet status.

Others see shared governance as a litmus test for how nursing is viewed within a hospital or healthcare system. “Shared governance speaks volumes about how nursing is respected,” said Ardelle Bigos, RN, MSN, CMSRN, CNO at Newton (N.J.) Memorial Hospital.

Bigos, who implemented shared governance at Newton Memorial in 2012, leads about 320 nurses. Her hospital is part of the Atlantic Health System, which includes three other hospitals — each in a different phase of implementing shared governance — together employing about 2,000 nurses. Bigos found that her hospital’s merger with the Atlantic Health System last year offered challenges to successfully launching shared governance. “There were processes that had to be decided upon between organizations, like equipment changes, [information technology], policies — and it was a whirlwind,” she said.

The complexities of implementation can be apparent to outside observers, as well. Laura Hailes, RN, a staff nurse at Nottingham University Hospital in the United Kingdom and the recipient of a Roosevelt Travelling Scholarship, spent four months visiting 13 hospitals, gathering information about shared governance and noting what makes the model function properly. “Three things go hand in hand: evidence-based practice, shared governance and a clinical ladder,” she said. “We don’t have shared governance, yet, back home. We’re working hard to improve EBP and career progression.”

But at some facilities, she explained, shared governance may seem like window dressing, not involving nurses enough in key decisions or affecting the way people view the profession. “Some nurses described shared governance as just, ‘The manager tells us our agenda and then we discuss it.’” said Hailes. “But if the manager is running the show, it’s not shared governance.”

From Hailes’ perspective, initiating shared governance is a long-term endeavor, a challenge she hopes to help accomplish at her hospital. “I think I’ll have to go about it slowly and gradually,” she said. “Shared governance is going to take a massive cultural change. Honestly, it’s basic good management.”


Susan Allen, RN
Investing time and money

For some hospitals, the process of integrating shared governance into their management structure is arduous and time consuming, considering the numerous teams that tackle topics such as nursing documentation, quality improvement, nursing standards, equipment purchasing and education. The decision-making systems of other departments, such as medical staff committees and top-level management, add to the complexity. “The biggest complaint has been that shared governance was too cumbersome,” said Allen.

And while participants often find ways to shave costs while maintaining or improving quality of care, the time it takes to make collective decisions can be seen as expensive. “Shared governance could be at risk as cost cutting happens,” said Allen. “If hospitals are looking at professionals as widgets, it’s in danger.”

Hess said it can be challenging to measure the actual effect of shared governance. “I can measure that it’s there, but the holy grail should be that it matters,” he said. “If we’re not improving patient care and practice, then it’s not working.”

Bigos said that for some organizations, the specter of creating a new, complex self-management structure is daunting. “It’s not all just flip the switch and it works,” she said. “Over time, though, it works. I’ve watched these nurses grow into leaders and I’ve seen relationships they’ve built, presenting in front of teams and the medical staff.”

In some facilities, groups fear shared governance because they don’t want to lose power or control, said Hess. “When people try to start up shared governance at a union hospital, it’s hard. Unions don’t want to lose their hold.”
Some think shared governance can help professionalize the nursing workforce at a hospital, decreasing the perceived need for unions. “If you’re managing your own practice, why would you want someone else doing it for you?” said Nancy English, RN, MSN, ACNF-BC, manager of nurse education at Newton Memorial. “There’s no reason to go looking for outside help when you have the availability to manage your own practice.”

Bigos said it’s critical that hospital and nursing leadership are well-informed about shared governance and are supportive.

Looking forward

As for the future of shared governance, Allen said it would be ideal to see whole-system integration involving all hospital staff. “But will shared governance ever be the sole governing system or will there always be a traditional system to manage operations? Shared governance would have to be highly integrated,” said Allen.

Experts suggest the next step is to build patients and the community into the shared governance model. Allen said Cincinnati Children’s Hospital has a family advisory council and a teen council that get involved in projects including reviewing potential educational materials and designing a new learning center.

Some see the lack of a standard educational entry level into nursing practice as a barrier to shared governance. “To develop as a profession, nursing has to come to grips with the BSN,” Bigos said.

Hess said he believes shared governance will continue to spread. “It’s hard to generalize, but when you walk into a shared governance hospital, the nurses conduct themselves differently,” said Hess.

To learn more, visit the Forum for Shared Governance at SharedGovernance.org.


Barbara Bronson Gray, RN, MN, is a freelance writer. Post a comment below or email specialty@nurse.com.
What the future holds — Three challenges

While nursing experts say there is now momentum behind the spread of shared governance, they acknowledge current trends in healthcare can pose challenges to implementing the programs. These challenges include:

• Mergers and acquisitions are increasing — It may be harder to create shared governance in multi-hospital systems, especially if decision making is highly centralized. Healthcare reform is likely to spur an increase in mergers and acquisitions. According to American Hospital Association data, the number of hospitals declined by about 3.5% from 5,194 in 1995 to 5,008 in 2011. Yet the number of hospitals affiliated with systems has been increasing. In 1999, only 2,524 of the hospitals in the U.S. were part of systems, but by 2009, that number had increased to 2,921.

• More physicians are becoming hospital employees — Hospitalists and specialists are increasingly becoming hospital employees, which could affect clinical integration and management systems, such as shared governance. Hospitals employed about 211,500 physicians in 2010, a 34% increase from 2000, according to the latest survey statistics from the AHA. The trend is driven by volume-based, fee-for-service charging and a desire to gain market share. Some hospitals have started to integrate hospital-employed physicians into shared governance.

• The demand for cost cutting is likely to rise — Shared governance seems to be more costly than a centralized, top-down decision making. Meetings take time, and staff nurses are given “relief time” to participate, while other nurses take their place in delivering nursing care. Shared decision making also can increase the time it takes to make a decision, since input is typically gathered from many people. If hospital costs increase or revenue decreases, hospital leaders may choose management methods they consider to be more efficient.