Professional nurses have a long history of struggling to deliver patient care against multiple barriers, including dwindling resources. As we speed into the current century, the struggle is increasing in complexity. This struggle affects not only individual nurses, but also patients, organizations, and the nursing profession. Nurses’ strong commitment to patient care and their role as patient advocates often places them in direct conflict with administrators of health care organizations. How nurses react to this conflict, how they continue to advocate for patients in this environment, and what resources they have available to improve patient care has become an increasingly important focus of the nursing profession and the health care industry. A recent report by the Institute of Medicine (IOM) (2004) entitled "Keeping Patients Safe: Transforming the Work Environment of Nurses" highlights the important role nurses provide in our complex health care system and provides recommendations for improving the workplace partnership between nurses and employing organizations. The ability of nurses and organizations to improve the workplace partnership is vital to the future success of health care (AHA, 2002; Gelinas & Bohlen, 2002; IOM, 2004).

It is important to the future of health care that ample strategies be identified to provide support for nurses as they take on the challenges of the new century. One organizational strategy that has long been stressed as a mechanism by which nurses can advocate for and manage their professional role is that of shared governance (SG) (McDonagh, Rodes, Sharkey, & Goodroe, 1989; Metcalf & Tate, 1995; Porter-O’Grady, 1987, 1991, 2001, 2003b; Porter-O’Grady & Finnigan, 1984). A newer strategy that promotes power bases that afford nurses optimal work environments is work place advocacy (WPA). This article attempts to identify common denominators that are part of both SG and WPA.

Shared Governance: An Organizational Strategy of Advocating for Excellence

Shared Governance as described by Porter-O’Grady (2001) was first introduced two decades ago to provide strategies for empowering nurses and a framework for organizing the work of nursing within organizational settings. SG is an organizational strategy through which nurses can express and mange their practice with a higher level of professional autonomy (Porter-O’Grady, 2003b). Most organizations employing SG strategies focus on creating a partnership between the organization and the individual nurse. This approach seeks to create an organizational environment where individual professional accountability is respected and encouraged. SG is focused on the micro level. Strategies are determined at the micro level (within the organization) rather than at the macro level (external to the organization).

Shared governance provides organizational support for direct-care nurses and enables them to become committed to quality nursing practice within their organizations.

Shared governance has long been identified by professional nurses as a key indicator of excellence in nursing practice (McDonagh et al., 1989; Metcalf & Tate, 1995; Porter-O’Grady, 1991, 2001, & 2003b). SG has attracted the attention of nurses and organizations over the last decade because it is perceived as a way to maintain nursing job satisfaction, quality care, and fiscal viability. During the past 15 years there has been a proliferation of organizations using SG to redesign care delivery roles and systems, thereby restructuring the governance of professional nursing within these organizations.

Shared governance provides organizational support for direct-care nurses and enables them to become committed to quality nursing practice within their organizations. Porter-O’Grady (2003) describes SG as reflecting a set of principles that give form to a particular conceptual framework, or group of strategies, that empower both workers and workplaces. According to Porter-O’Grady (2003b), SG is an organizational strategy that employs the attributes of partnership, equity, accountability, and ownership between the worker and the workplace. These attributes are important factors in nursing job satisfaction (IOM, 2004, Porter-O’Grady, 2003b). SG strategies or programs render both a structure and an environment which empower nurses to make care decisions. The many benefits of SG are described in other articles in this January 2004 Online Journal of Issues in Nursing topic discussing the concept of shared governance.

Workplace Advocacy: A Professional Strategy of Advocating for Excellence

Work Place Advocacy operates at the organizational, local, state, and/or national levels to equip nurses to skillfully use a range of external (macro) and internal (micro) strategies that are complementary in nature.

Work Place Advocacy operates at the organizational, local, state, and/or national levels to equip nurses to skillfully use a range of external...and internal...strategies that are complementary in nature.

These strategies focus on strengthening nursing’s voice and ensuring nurse involvement in workplace decisions that affect nursing care (Green & Jordan, 2002). Developing an effective WPA strategy or program is a complex, multifaceted task involving both individual nurses and professional organizations, such as national and state nurses associations.

Macro level strategies would likely focus on either local, state, or federal policies that are capable of directly impacting professional nursing practice. These types of policy initiatives are usually begun by state or national professional nursing organizations, although they may also be initiated by other stakeholder groups, such as the American Hospital Association. Examples of such initiatives that have resulted in legislation of health policy include: state-regulated, mandatory safe staffing rules and national workplace safety initiatives, such as protection of confidentiality in reporting of workplace injury or illnesses. Individual nurses have a professional obligation to participate in macro level activities, via membership in state or national professional nursing organizations, to improve nursing practice environments and patient care delivery systems.

Advocating for the nursing profession and/or professional practice has been a priority of professional nursing organizations for many years. In particular, the American Nurses Association (ANA) has long been working to define the programs and services intended to promote and support professional practice standards in the workplace (ANA, 1999). These activities support nurses’ advocacy for their patients, professional practice self-determination, and the exercise of nurses’ employment rights and responsibilities.

Individual nurses have a professional obligation to participate in macro level activities, via membership in state or national professional nursing organizations, to improve nursing practice environments and patient care delivery systems.

In 2000, the ANA committed to supporting the profession through WPA with the formation of the Commission on Workplace Advocacy (CWPA). That commitment was further refined in 2003 by structural changes within ANA resulting in the creation of the Center for American Nurses (CAN), formerly the Center for Work Place Advocacy (CWPA) (ANA, 2003). Information about the CAN can be found at www.centerforamericannurses.org.

The CAN is an independent, national professional association affiliated with the American Nurses Association that was designed to form a partnership between the thirty-eight participating state nurses associations and the practicing registered nurse. Most of the remaining states not involved in the CAN prefer to utilize collective bargaining as their primary strategy for impacting the workplace. The goal of the CAN is to develop cutting-edge strategies, including products and programs that will help nurses to optimize their value in the workplace. As the American workforce changes in the 21^st century, nurses will desire new and diverse opportunities to influence their workplace and the CAN will provide the pathways needed to achieve this empowerment.

The CAN has identified many approaches to optimize the voice of the practicing nurse in health care settings. Many of these approaches parallel SG in that they bring the nurse to the decision table. Nurses’ success at that table will be a function of individual nurse’s skills and abilities, as well as employers’ reasons for wanting the nurse present at this table. Nurses can empower themselves by seeking guidance and assistance from the CAN as they strive to strengthen their positions in health care organizations through the use of SG and WPA strategies.

Micro level CAN activities occur at the organizational level where the nurse is employed. Examples of micro level WPA strategies are: advocating for appropriate staffing levels within the organization and developing organizational level workplace safety programs to prevent ergonomic injuries. These improvements occur when individual nurses take leadership in implementing WPA awareness within their organizational settings.

Common Denominators in Shared Governance and Work Place Advocacy

Common Denominators in Shared Governance and Work Place Advocacy include: accountability, empowerment, conflict resolution, and patient advocacy. Each of these denominators will be discussed below.

Accountability

Accountability forms the foundation for designing WPA and SG strategies (Green & Jordan, 2002; Metcalf & Tate, 1995; Porter-O’Grady, 1991, 2001, & 2003b). Authority to make decisions for all professional nursing responsibilities is an essential element of nursing accountability.

To be a successful and accountable professional, it is essential that nurses recognize current workplace issues and know how to seek the support needed to address these issues in the workplace.

To be a successful and accountable professional, it is essential that nurses recognize current workplace issues and know how to seek the support needed to address these issues in the workplace.

According to Porter-O’Grady (2003b), SG provides a structural format within an organization through which nurses can express and manage their practice with a higher level of professional autonomy, resulting in greater accountability within an organization. An example of enhanced professional accountability under SG would be the implementation of a peer review system within the work place that would promote professional accountability for the delivery of quality nursing care.

Work Place Advocacy, utilizing a macro level approach, provides a similar context for impacting professional accountability within the profession. Nurses involved in WPA would look not only at their own employment setting to ensure accountability, but would seek opportunities to enhance accountability within a larger context, such as professional peer review by a statewide review system. This would result in accountability for all nurses within the state.

Empowerment

Work Place Advocacy and Shared Governance can both empower the nurse to provide quality patient care. These strategies are complementary in nature, focusing on strengthening nursing’s voice and ensuring nurses’ involvement in workplace decisions that affect patient care. Shared governance focuses on the micro level of the organization, while WPA includes the organizational level of involvement and extends beyond to the larger health care system.

Organizational policies, such as nurse staffing, can be influenced by participation of nurses in a hospital’s nurse management council. Management councils are hallmarks of SG strategies and serve as examples of how SG has an influence at the micro level. Staff nurses involved in the hospital’s management council could additionally become active in advocating for policy changes at the state (macro) level, where statewide staffing rules are developed and implemented. Whether operating at the micro or macro level, empowered nurses can improve the environment and enhance delivery of quality health care.

Conflict Resolution

According to Porter-O’Grady (2003a), many organizational structures reflect a parent-child system of interaction and communication between mangers and staff. Such structures reflect a vertical notion of power, interaction, and authority, and often lead to conflict. To improve the patient care delivery system and work environment, new leadership structures should engage nursing staff in nonhierarchical decision making and work design (IOM, 2004) by providing decision support and conflict resolution at the point of care delivery.

Organizations that effectively incorporate conflict resolution into their shared governance strategies provide support for nurses to learn and practice these highly specialized and important negotiation skills.

Principles embedded in conflict resolution (collaborative) strategies can enhance nursing empowerment; however, conflict resolution is an area in which nurses typically have limited skills. In the ideal world, health care organizations would embrace conflict resolution strategies as the standard way of doing business. In reality, nursing may have to take the lead by adopting the principles of conflict resolution.

Effective SG strategies include principles of conflict resolution and assist nurses in identifying and managing conflict. Organizations that effectively incorporate conflict resolution into their shared governance strategies provide support for nurses to learn and practice these highly specialized and important negotiation skills. Effective SG strategies provide specific channels of communication for conflict resolution within individual organizational settings and adequately prepare nurses to effectively deal with conflicts arising around patient care and physician-related issues.

The effective use of conflict resolution strategies is being developed and modified for the entire health care industry by WPA groups. Use of these strategies moves health care from a hierarchical model of communication to a model where conflict is resolved at the lowest level, i.e., the level at which conflict occurs. For nurses, this is often the bedside level. The effective use of conflict resolution reduces cost, provides more empowered and satisfied workers, and results in higher quality outcomes (Slaikeu, 1996). These strategies, which can also reduce the use of costly litigation, can serve nurses, other professionals, patients, and the organization.

Effective WPA and SG strategies should ensure that all nursing policies call for conflict to be resolved at the level at which the conflict occurs. It is also essential that organizations provide training for all nurses regarding conflict resolution, collaboration, and practical approaches for analyzing disputes and using informal mediation. Effective WPA programs, such as those currently under design by state or national associations, may provide external resources to nurses that are not part of the organization. To effectively utilize conflict resolution strategies, nurses need to develop skills in conflict analysis, collaboration, and mediation. Because most nurses at this time have limited exposure to effective conflict resolution techniques, they are encouraged to use outside coaching to assist in conflict resolution when needed. This might involve access to a call center hotline or a certified nurse ombudsman offered through a state level WPA program.

Patient Advocacy

Patient advocacy is a cornerstone of the nursing profession; patients depend on nurses to ensure that they receive proper care. Although nurses have always advocated for their patients, it has only been during the last 25 years that the formal role of the nurse as "patient advocate" has begun to emerge (Green & Jordan, 2002). The evolution of the nurse’s role in patient advocacy has changed from a vague assertion of ethical-legal responsibility in the mid 1970’s to a "rights" framework in the 1980s (Mallik & Rafferty, 2000).

Both SG and WPA support the "rights" framework, particularly as it relates to assuring a safe health care environment for delivery of patient care. Today, errors and adverse events are attributed to problems in complex systems and technologies. Such situations demand that nurses assert their powerful voices in their role of and right to patient advocacy. SG provides a structural mechanism within organizations whereby nurses speak up to improve practices, and thus promote the safest and best possible outcomes for patients. On a broader scale, nurses involved in WPA have access to information to assist them in identifying state/national reporting mechanisms to report concerns about health care organizations and/or professionals.

Summary

In examining the common denominators of SG and WPA, it becomes clear that both approaches can indeed improve the status of nurses in the workplace, as well as improve the quality of nursing care delivered. SG and WPA are strategies for nurses to gain control over their practice and promote professional autonomy by providing transformational leadership for an organization and for the profession. Knowledge is the single most valuable asset a nurse brings to the workplace (Porter-O’Grady, 2003a). Nurses empowered with knowledge to promote accountability, empowerment, conflict resolution, and patient advocacy via SG and WPA strategies can shape a win-win situation for the nursing profession, for health care organizations, and most importantly for consumers of health care services.

Authors

Alexia Green, PhD, RN, FAAN
E-mail: alexia.green@ttuhsc.edu

Alexia Green, PhD, RN, FAAN is Dean and Professor at the Texas Tech University Health Sciences (TTUHSC), School of Nursing. Her career has focused on teaching and practice in the areas of adult health, critical care, and public policy. She is currently a Robert Wood Johnson Executive Nurse Fellow (Class of 2001). Her professional activities include serving as immediate past President of the Texas Nurses Association and providing significant leadership in addressing public policy issues related to solving the nursing shortage and other workplace issues. Alexia served as a member of the American Nurses Association’s Committee on Workplace Advocacy. Coalition building is one of her strengths, having served as founding member of the Texas Nursing Education Policy Coalition, the Texas Nursing Legislative Agenda Policy Coalition, and the Texas Patient Safety Alliance. Her leadership in a community coalition has resulted in a recent $2.9 million grant award from the U.S. Department of Labor to address the nursing shortage in West Texas. Alexia has a long history of political activism and advocacy in the health care arena, and has testified thirteen times before state and regulatory entities regarding nursing and health care policy issues. In addition, she has also held an elected political position in Texas, as the first woman ever to be elected to her local school board in the 56-year history of the school district. Awards include recognition as a Distinguished Lecturer by Sigma Theta Tau International, Great 100 Nursing Alumni of Texas Woman’s University, and Teacher of the Year from the Texas Nursing Student Association. Alexia is a native Texan, currently residing in Lubbock.

Clair Jordan, MSN, RN
E-mail: cjordan@texasnurses.org

Clair Jordan, MSN, RN is the Executive Director for Texas Nurses Association (TNA) and Texas Nurses Foundation (TNF). She is responsible for administration of programs of the TNA and TNF as well as serving as a lobbyist and administrator for the Political Action Committee. Clair has served as member of various nursing, health and women’s organizations. She has served on state level committees of the Texas Society of Association Executives and was a member of the American Nurses Association’s Congress of Nursing Economics from 1992-1996. Ms. Jordan is also a member of the American Nurses Association’s Committee on Workplace Advocacy and the current President of the Center for American Nurses.

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