Shared Governance: A Nurse Executive Response

Shared Governance is an idealized state that many nurse leaders strive to achieve. As a concept in the nurse leader's tool kit of 'best practices', many leaders find that shared governance is attainable; others find that reaching this state of organizational and nurse empowerment is elusive. Dr. Hess proposes that the new nursing shortage is bringing attention once again to the draw of shared governance models where nurses have control over their practice and exert influence over decisions that affect their practice. While some organizations have recently embraced the shared governance strategy with renewed vigor, others have worked long and hard to make shared governance a reality and an integral part of the organizations' operations. The following observations are brought to the reader from the perspective of a nurse executive immersed in major health system transformation at a time of critical under-availability of professional nurses.

It's First About Leadership

From the corporate office to the front lines of care, effective, contemporary nursing leadership is essential for transformation of traditional hierarchical structures and processes into those that are inclusive and empowering. Across the profession, there is still much to be accomplished in having the right people with the right capacity to guide this work. Even though there is widely accepted evidence that an involved, engaged, and empowered professional is more satisfied with the profession and workplace, and outcomes for patients are improved, there remain widely held beliefs that empowering nurses through governance models decreases the need for leadership positions. In reality, assuming that such a transformation is desired in an organization, senior nurse leaders must continue their work to ensure the right "who" in critical nursing leadership positions and provide them with the ongoing development they may need to guide and mentor their nursing colleagues to true ownership of professional decisions and to implement sustainable governance models. As Collins (2001) advises, focus first on the who, and then on the what.

Structure versus Process

Porter-O'Grady (2003) indicates that shared governance is "a structural model through which nurses can express and manage their practice with a higher level of professional autonomy" (p. 251). Whether nurses are able to achieve that result through changes in organizational processes or through implementation of a formal model for involvement is not what's most important to the nurse executive seeking to achieve this outcome for professionals within the organization. What matters is that the outcome happens and that nurses value it. Dr. Hess (2004) suggests that structure is vital to shared governance; however, structural variation is apparent across the industry and is reflective in successes attained by various hospitals. Hospitals certainly have their own cultures and the governance approach needs to fit a given culture to be successful.

As nurse leaders seek ways of leading new models for autonomy, empowerment, and shared governance, a long journey can be anticipated. Incremental progress must be celebrated. Viewing the journey as a continuum to which higher and higher levels are attained is most important to those engaged in embracing change and to those leading the charge.

Additional Attention Needed

Nurse executives are challenged by complex health care and nursing administrative issues and have intense time constraints. This is a fact that cannot be anticipated to change in any foreseeable future. Attention to the adoption of governance models as appropriate for an organization is time intensive, and requires the attention of all leaders within that organization. Additional areas where professional attention is needed from all organizational leaders are described below.

First, nurse executives, their senior colleagues, and their leadership teams must set the stage for transformation and guide practicing nurses into an era of acceptance of accountability before empowerment and involvement in governance can occur. In many organizations today, there are role-stressed nurses who claim to not want empowerment. Leaders must sort through issues surrounding this cultural state to understand the root causes and then take appropriate action to change the culture and indeed transform the face of the professional practice setting.

There is an acute need to increase the socialization of students regarding professional accountability and to partner them with positive role models in the practice setting. Partnerships between education and practice settings must mature so that students of professional nursing are exposed early to the accountable, empowered nurse role model and the processes and/or structures in which they participate.

A focus on developing the capacity of nurses in leadership roles to guide changes in the work environment that set the stage for shared governance to be successful is the greatest area of needed attention. As Porter-O'Grady and Mallock (2002) write regarding empowerment, "The goal is to transfer leadership wisdom not only to aspiring leaders but to all employees. Along this journey, expert leaders provide tools for employees to do their jobs well and to help them feel successful" (p. 248).

Programs that prepare nurse leaders must ensure that the nurse leaders have the tools to do such work and that appropriate senior leadership role models are available. Those who provide development programs for nurses already in leader roles must incorporate experiential opportunities to support development of the level of expertise so needed to implement models for the future.

As the debate over researching shared governance continues (Hess, 2004; Porter-O'Grady, 2003), nurse executives need additional evidence that sorts actual costs of various shared governance models versus the return on investment (ROI) within the context of the current health care environment. More information is needed regarding examining the ROI in terms of what is attained when the shared governance approach is correlated to other organizational metrics such as retention rates, nurse satisfaction, and vacancy.

Conclusion

Dr. Hess provides nurse leaders 'food for thought' about approaching a renewed interest in shared governance models. Knowing that the work of ensuring the environment and support for shared governance is indeed a journey, and one that is long, is encouraging to those on the journey. Additionally, understanding the idea that not every organization will be able to attain a full governance model because of influencing factors is important. Not addressed by Hess in this Online Journal of Issues in Nursing Shared Governance topic (2004) is the point that empowerment in its basic sense is something that individual nurses can embrace as they view their own practice. Shared governance models then serve as vehicles for accelerating that empowerment.

Author

Donna M. Herrin, MSN, RN, CNAA, CHE
Email: Herrind@methodisthealth.org

Donna Herrin is currently Senior Vice President and Chief Nurse Executive at the corporate level for Methodist Healthcare in Memphis, Tennessee. Methodist Healthcare is an integrated delivery system serving West Tennessee, Eastern Arkansas, and North Mississippi with 8 hospitals; 9,000 employees; and almost 2,000 licensed beds. Prior to joining Methodist, Donna held positions of Vice President, Patient Care and Workforce Development Executive with Baptist Health System in Knoxville, and has served in with other health care systems as Associate Administrator, Chief Nursing Officer, and Director of Patient Care and Women’s Services. She is also Assistant Dean for Methodist Healthcare-University Practice at the University of Tennessee Health Sciences Center, Memphis and Clinical Associate Professor at the University of Alabama in Huntsville. Donna is involved with a number of professional organizations including the American Organization of Nurse Executives (AONE) where she has recently been elected Chair of the Finance Committee. She also completed a term on the national AONE board of directors and chaired the AONE National Education and Research Committee. She is a member of Sigma Theta Tau, the American Nurses Association, and the American College of Healthcare Executives. She serves on the editorial boards of the Journal of Nursing Administration, and Nursing Leadership Forum, has published on nursing leadership topics, and is an appraiser for the American Nurses Credentialing Center’s (ANCC) Magnet Recognition Program. Donna hold a master’s degree from Vanderbilt University, and is board certified as both a Healthcare Executive by the ACHE and as a nurse administrator-advanced by the ANCC.