Over the past 25 years, there has been continuous discussion regarding the meaning and value of empowerment concepts and structural contexts for nursing practice. Ever since the first structural considerations of shared governance were identified by Virginia Clealand in 1975, there has been a flurry of models, activities, and studies that look at this format for empowered decision making. Since I began to document the theoretical underpinnings of shared governance and suggest models that might encompass its principles, a large number of nursing organizations in a variety of settings have struggled to apply its principles and to construct organizational configurations which best exemplify shared decision-making practices. Now the American Nurses Credentialing Center’s (ANCC) Magnet Excellence program has within its core criteria for excellence a significant emphasis on nursing’s control of and participation in its own professional activities and influence over the delivery of patient care. While for some mysterious and inexplicable reason ANCC has failed to actually use the words "shared governance," the vast majority of the hospitals that have achieved "magnet status" use shared governance as their structural model for sustaining professional nursing practice. Indeed, most of these hospitals wouldn’t have obtained, nor sustained, their "magnet status" without it.
As all of the articles in this topic clearly point out, shared governance is a relevant and vital issue in the structuring of professional practice. While it is not unilaterally grounded in nursing theory (and what really is?), it fits well with the practice character and form of professional nursing. In the examples outlined in this Shared Governance topic, and throughout the places where nurses practice within shared decision-making models, there is ample support for sustainable shared governance structures. What is also clear as one reads the authors in this OJIN topic is that implementing and sustaining shared governance is not easy. To do so calls for a real congruence between management behavior and the structural imperatives of a shared decision-making model. What must happen is a synthesis between the staff’s competence in making their own decisions about practice, and their profession and the leader’s ability to facilitate them. Leadership must be able to create a safe and developmental context for both staff and themselves so that the trials associated with a considerable change in the traditional locus-of-control can be safely confronted, and professional practice can truly evolve.
For those who want to reflect on the journey of shared governance over the past 25 years, they have in the opening article by Hess, their best opportunity. Hess offers an overview of the processes and research on shared governance, with some reflections on their implications. Of particular value are the varieties of approaches and models that use the principles of shared governance. Hess’ article clearly provides the reader with a sense of the breadth of approaches that can be used to implement the principle of shared decision making. In addition, this topic includes two guest author responses to the Hess article from Brooks and Herrin.
If one wants to understand the relationship between shared governance and autonomy and professional practice, Caramanica demonstrates there is no need to go further than Hartford Hospital’s experience. Here the journey to professional practice is embedded in their implementation process, and the goals of advancing autonomy and improving practice have been well met. Of special interest is the growth in interdisciplinary relationships reflecting a level of clinical interaction that advances the work of the profession and clearly impacts good patient care. This is a model of how shared governance is done well.
There is nothing more exciting than the initiation of a powerful new way of relating and interacting in organizations. Thompson and colleagues describe their experience of implementing shared governance and the stages they moved through to make it viable and effective. Well articulated here is the impact of a strong and effective leader, the implications of a carefully thought out implementation process, and what this powerful combination does to create an effective shared governance structure. The overlay of the United Kingdom’s National Health Service points out how amenable shared governance is to different social and cultural circumstances.
Anthony offers a great review of the evidence of shared governance from concept to model across the spectrum of both the concept and its associated structures. This detailed review of the literature regarding shared governance should now become the data source for anyone looking for a comprehensive assessment of the past two decades of shared governance pursuits. Of equal importance in this article are the questions and challenges that are raised as the journey continues toward professional accountability, autonomy, and practice.
While collective bargaining is not traditionally seen as shared governance activity, it certainly falls well within the context of shared decision making. As an option, collective bargaining provides a mechanism for nurses to undertake a legally sanctioned approach to participation in decision making within clearly defined and prescribed parameters. Furthermore, the right to collective bargaining is an essential democratic principle that must always be available as one of the compendium of responses for collective professional action.Budd, Warino, and Patton perhaps better than most, point out the real value of collective bargaining and the extent to which it can support collective decision making. It serves as a viable mechanism for nurses to respond to issues that dramatically affect their ability to do nursing’s work and also issues that affect the delivery of patient care. This article enumerates the concerns, circumstances, and conditions that require nurses to be proactive and to take an active interest in advancing the practice of nursing and in providing care. As a reasoned advocacy for the role of collective bargaining in shared decision making, this article is one of the best.
By whatever rubric one uses, it is always good to focus on the quality of the workplace and its impact on the effectiveness of the work life. Work place advocacy clearly has in it a number of processes that are important to the activities of an effective workplace, and these models are well articulated by Green and Jordan. Just as shared governance is about good infrastructure that sustains good process, Green and Jordan enumerate what some of these good processes are for a successful work life. In addition, this article identifies the points of good fit between work place advocacy and shared governance. The reader would do well to make the practices outlined here the way of doing business for every health care organization.
Interestingly enough, there is very little question that empowering models such as shared governance are good and valuable corollaries to professional practice and good leadership. What research exists, as is well enumerated in this topic, more than validates that there is little that is negative in this approach. What is missing is stronger and more focused longitudinal shared governance research related to the deepening and broadening of professional practice, the cost-benefit impact, and value of shared governance with regard to advancing patient care outcomes. As shared governance becomes more clearly articulated as the structural centerpiece of "Magnet Excellence," we will see more of this data emerge.
The more dialogue, publication, and debate regarding the value of shared decision-making initiatives such as shared governance, the stronger nursing’s sense will be of how important it is to true professionalism and effective practice. In today’s world of transformative health care and the changing technological framework for practice, there is simply no way that nurses can continue in hierarchical and professionally passive organizational configurations. There is much to be done to challenge the profession in every place it practices to become renewed and different, in an effort to assure that nursing practice is relevant and viable in the 21st century. It is simply unimaginable that nurses would believe that organizations and systems in which nurses do not play the central clinical decision-making role could ever survive this time of major reformation toward a technologically founded and "user-driven" health care future. As the articles in this topic clearly evidence, shared governance makes it impossible to do "business as usual" in today’s health care. And after all, isn’t shared governance, at the very least, a format for all nurses to own their practice and join in a collective effort to advance the value and quality of health care for all? That’s what it means to me to be a nurse. It is clear, we simply can’t do that work alone. Shared governance isn’t an option; it’s an expectation.
We would invite other nurses with experience in shared governance concepts, implementation, and/or research to contribute to this ongoing dialogue regarding the value, efficacy, and processes of nursing shared governance. Shared governance models reflect a maturing of the profession and the structures that support its work. If you are involved in any shared governance process, including those associated with "Magnet Excellence" activities, please consider submitting an article to the Online Journal of Issues in Nursing for consideration. We look forward to your participation in ongoing dialogue to advance the profession of nursing and improve the quality of care provided to those whom we serve.
Tim Porter-O'Grady, EdD, RN, CS, FAAN
Tim Porter-O'Grady, EdD, RN, CS, FAAN, is a senior partner at TPOG Associates, LLC. Dr. Porter-O'Grady is the author of multiple publications on the topic of shared governance in nursing. He is an Associate Professor at Emory University in Atlanta, GA. Dr. Porter-O'Grady has worked with over 750 organizations in the design and implementation of newer workplace and clinical models of health care, as well as shared decision-making structures across the United States, Europe, and Asia. He has focused his practice on clinical leadership development to foster professional practice environments. Tim has written 13 books and over 150 journal articles on a wide variety of topics related to creating and sustaining a professional practice environment and to new models of clinical leadership and nursing practice within the context of the 21st century.