WEEK 7 DISC
NURSING PRACTICE & SKILL
Authors Mary Woten, RN, BSN
Cinahl Information Systems, Glendale, CA
Arsi L. Karakashian, RN, BSN Armenian American Medical Society of
California
Reviewers Bryan Boling, RN, DNP, CCRN-CSC
Cinahl Information Systems, Glendale, CA
Sara Richards, MSN, RN Cinahl Information Systems, Glendale, CA
Nursing Executive Practice Council Glendale Adventist Medical Center,
Glendale, CA
Editor Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA
November 16, 2018
Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2018, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
Shared Governance: Understanding the Decision- Making Process
What is the Decision-Making Process in Shared Governance? › Shared governance is a professional practice model that promotes nursing empowerment
and shared decision-making by making staff nurses accountable for decisions that impact policies, procedures, and processes at the point of service • What: Understanding the decision-making process in shared governance involves
assessing and evaluating the ways in which nurses participate in decision-making within healthcare organizations that utilize a shared governance structure
• How: Understanding the decision-making process in shared governance is accomplished through a process of individual and group assessment and evaluation of the various methods that are utilized for decision-making in healthcare organizations with a shared governance structure
• Where: Understanding the decision-making process in shared governance is performed in all clinical areas and at all levels of the healthcare organization
• Who: Understanding the decision-making process in shared governance is performed by nurses at all levels of the organization who function in a variety of nursing roles
What is the Desired Outcome of Understanding the Decision- Making Process in Shared Governance? › Understanding the decision-making process in shared governance will promote staff nurse
participation in shared governance in general and in the process of decision-making in particular
Why is Understanding the Decision-Making Process in Shared Governance Important? › Staff nurse participation in decision-making related to patient care and nursing practice is
vital to the successful implementation of shared governance • Understanding the decision-making process is necessary to effective participation in
decision-making • As nurses participate as point-of-care decision makers, they share control of their
environment and become more engaged, increasing in productivity and positivity, ultimately leading to better patient care
Facts and Figures › The shared governance model was developed in the mid-1980s as an alternative to
traditional bureaucratic organization models. Board members, nurses, physicians, and managers participate in the shared governance model to enhance professional communication and decision-making practices (Marquis et al., 2015)
› The American Nurses Credentialing Center (ANCC) developed the Magnet® Recognition Program in 1991 to formally recognize those hospitals meeting magnet hospital criteria. The Magnet model requires that hospitals implement strategies to provide high-quality health care and patient outcomes, including components of transformational leadership, exemplary professional practice, and new knowledge, innovations, improvements, and structural empowerment (ANCC, n.d.)
› The ANCC defines the process of structural empowerment as “including nurses in shared governance and decision-making structures and processes to establish standards of practice and address opportunities for improvement. Nurse leaders serve on decision-making bodies that address excellence in patient care and the safe, efficient, and effective operation of the organization” (ANCC, n.d.)
› Investigators in a study analyzing differences between direct care nurses’ perceptions and nurse managers’ perceptions found that although 79.2% of the 144 nurses participated in shared governance activities, nurse managers reported more engagement in the activities compared to direct care nurses (Wilson et al., 2014)
› Sustaining a shared governance structure in nursing practice requires defining the problem; discovering strengths and weaknesses to improve positive qualities; remaining open-minded and accepting; designing proactive improvements and reviewing suggestions; and delivering recommendations in writing to the leadership council of the organization (Meline & Brehm, 2015)
› Developing formal mentoring structures for current and future nursing leaders (e.g., president-elect) is a strategy that can be used to improve professional growth and shared governance (Catrambone et al., 2014)
› Flat organizations in which there is direct communication between nurses and healthcare providers, is most effective in shared governance decision-making. Shared governance decision-making is more difficult in a more rigid structure, in which information is shared in a hierarchal manner (Alrwaihi et al., 2018)
What You Need to Know Before Understanding the Decision-Making Process in Shared Governance › Shared governance
• provides a structure for decentralized, shared decision-making in which nurses and managers work in partnership to achieve organizational goals – Staff nurses and managers must be educated regarding the expected outcomes and reasons for implementing shared
governance • empowers staff nurses to be in control of their nursing practice by placing the locus of control for nursing practice
decisions at the point of service – Empowerment involves recognizing and allowing the expression of the power inherent in the nursing role – Staff nurses become empowered to be accountable for all policies, procedures, and processes related to nursing practice,
including patient care, quality of care, professional competence, staff development, peer relations, and credentialing; managers remain accountable only for those policies, procedures, and processes uniquely related to the management role (e.g., staffing, finance, interdepartmental issues, resource management)
• requires a change in attitude as well as a change in the culture of decision-making for the nursing unit and the healthcare organization as a whole – Staff nurses must be supported to make and be accountable for decision-making, and managers must be supported to
relinquish control over decision-making • requires an adjustment in staff nurse and manager roles, with staff nurses assuming a greater role in decision-making and
managers assuming more of a facilitator role – Nurse managers must accept and welcome change and remain focused and positive during the transition to shared
governance – Nurse managers should educate nurses on the meaning of shared governance and how nurses can be involved in the
decision-making process – The leadership style of nurse managers is a significant influencing factor in successfully involving staff nurses in shared
governance. Nurse managers should be transformational leaders, as opposed to transactional and laissez-faireleaders. Transformational leaders are: - proactive, setting goals for staff to achieve higher levels of performance - encouraging, recognizing excellence within their organization and being aware and learning from the struggles and
successes of other organizations - seeking to cultivate change through innovation
• has been shown to decrease health resource utilization and equipment costs, but has demonstrated mixed results with regard to increasing nursing job satisfaction, autonomy, and commitment; reducing job turnover; and improving conflict management
• requires an initial financial investment from the organization for education and an ongoing financial investment for staff nurses attending shared governance-related meetings
• is required for hospitals seeking American Nursing Credentialing Center (ANCC) magnet designation
› There are four models of shared governance • The unit-based model places responsibility for decision-making at the unit level, with no coordination of activities between
units or throughout the organization • The councilor model places the responsibility for decision-making in organization-wide councils that have a particular
focus (e.g., nursing research, professional development) and are composed of staff nurses from a variety of units • The congressional model involves staff nurses in decision-making in an organizational structure that is similar to the United
States Congress • The administrative model utilizes two separate committees for clinical staff and management staff, each of which report to
an executive committee that has responsibility for making all final decisions › For shared governance to be successful, nurse managers and council members need to understand three key components:
• Responsibility: delegating job duties in order to achieve the desired results • Authority: the right and need for point of care decisions • Accountability: the ability to reflect on decisions which were made, and to objectively evaluate the effectiveness of the
actions taken › The decision-making process involves the following steps:
• Identify the decision to be made – Determine that the person, committee, or organization has the authority to make the decision
• Gather data to explore the decision – Use an evidence-based approach to gathering data (e.g., perform a literature search)
• Identify the criteria for making the decision – Reflect on the objectives for the decision to be sure that any decision made will be in alignment with overall
organizational objectives • Generate possible alternatives
– At least two alternatives must be generated, although generating more alternatives promotes a more thorough decision-making process
• Choose an alternative (i.e., make the decision) – Use logic when choosing an alternative; do not choose an alternative based on emotions or a desire to maintain the status
quo • Implement the decision
– Once a decision is made, it should be implemented immediately • Evaluate outcomes of the decision and the decision-making process
– If a decision is found to be ineffective or the decision-making process was performed inappropriately, the process can be repeated and a new decision made
› Decision-making in shared governance • is knowledge or evidence based • occurs by consensus at the point of service in a committee or council environment
– Shared governance models typically involve councils (i.e., unit-based councils [UBCs] and/or specialty councils) that meet regularly to make decisions that impact nursing practice - Councils can have 12–15 members, require majority agreement to change nursing practice, and are governed by
self-created bylaws • is dependent on shared goals and a high level of nursing staff participation • requires direct communication and collaboration among the involved staff nurses
– Shared governance cannot occur without effective communication • requires collegiality and partnership between staff nurses and nursing management
– Staff nurse and nurse manager roles must be clearly delineated • integrates
– partnership (i.e., interdependent relationships among staff members) – equity (i.e., the contribution of each staff member is valued)
- Any nurse can bring an item or concern to any council for consideration – accountability (i.e., the person or group making the decision has the power to make the decision [authority], the right to
make the decision [autonomy], and the ability to implement the decision [control]) - Staff nurses are empowered to make decisions (i.e., demonstrate authority) by nurse managers who support them in
recognizing the power inherent in the staff nurse role
- Staff nurses only have the authority to make those decisions that are within their scope of practice – ownership (i.e., staff members are invested in the organization and have a stake in the outcomes of all decisions)
• takes longer than the process for traditional decision-making › The decision-making process in shared governance begins when a nurse brings an issue to a council for consideration (e.g., a
concern regarding nurse coverage on the floor during shift change when verbal report is given) • The issue is added to the council’s meeting agenda • At the next available council meeting, the council
– discusses the issue - Each member of the council is encouraged to provide input into the discussion
– makes a decision via consensus to either research the issue for a possible change in nursing practice or leave the practice unchanged (e.g., decide either to research changing the current procedure for nurse coverage on the floor during shift change or leave shift change the way it currently is)
• If the council decides to pursue the issue, the council – assigns the issue to a council member to research (e.g., perform a literature search, assess current practices on other units
or in other organizations) and devise possible alternative solutions – determines a time frame for resolution of the issue (e.g., present the research and make a decision at the next council
meeting) • At the next council meeting (or later, depending on the amount of research to be done and the time frame for resolution),
the assigned council member – presents what he/she has learned about the issue – offers possible alternatives to resolve the issue and improve nursing practice (e.g., to change to a tape-recorded or written
shift report), including the advantages and disadvantages of each solution • The council
– discusses the issue and the alternatives presented – makes a decision via consensus, according to the bylaws of the council, or leaves the current nursing practice unchanged
• Once a decision is made to change current nursing practice, a plan is created to – communicate the decision to the unit(s) or nurses that will be affected by the change in nursing practice – implement the change as soon as possible (e.g., immediately procure tape recorders to implement tape-recorded shift
report) – schedule evaluation of the outcomes of the decision (e.g., in three months evaluate if having tape-recorded shift report has
improved nurse coverage on the floor during report) and the decision-making process • Evaluate the outcomes of the decision and the decision-makingprocess
– Repeat the decision-making process if the outcomes of the decision are not satisfactory › Before attempting to understand the decision-making process in shared governance, nurses must be informed regarding the
specific implementation of shared governance in the organization
How to Understand the Decision-Making Process in Shared Governance › Identify an issue involving nursing practice that, if changed, would improve patient care
• Bring the issue to the UBC or the appropriate specialty nursing council for consideration • Add the issue to the council meeting agenda for the next available council meeting • Discuss the issue at the council meeting • Decide via consensus if the council will explore a change in nursing practice to resolve the issue
– Encourage each member of the council to provide input into the discussion • If the decision is made to explore a change in nursing practice to resolve the issue, assign the issue to one council member
to research • Determine a time frame for resolution of the issue
› Gather data to explore the issue • Research the issue using an evidence-based approach (e.g., perform a literature search, assess current practice in other units
and/or organizations) › Identify the criteria for making the decision
• Determine if the objectives for the decision are in alignment with overall organizational objectives › Generate possible alternatives
• Devise at least two alternative solutions
› Choose an alternative (make the decision) • Present the research on the issue to the council at the next council meeting or according to the timeline for resolution • Offer and discuss the alternative solutions to resolve the issue, including the advantages and disadvantages of each • Choose one of the alternative solutions via consensus, according to the bylaws of the council, or leave the current nursing
practice unchanged – Choose an alternative based on logic, not emotions or a desire to maintain the current practice
› Implement the decision • Communicate the decision to the unit(s) or nurses that will be affected by the change in nursing practice • Make plans to implement the change as soon as possible • Set a time frame for evaluating the outcomes of the decision and the decision-making process
› Evaluate the outcomes of the decision and the decision-making process • Repeat the decision-making process if the outcomes of the decision are not satisfactory
What to Expect After Understanding the Decision-Making Process in Shared Governance › Understanding the decision-making process in shared governance will promote staff nurse participation in shared governance
in general and participation in decision-making in particular
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