Article Review B

JONA Volume 47, Number 7/8, pp 396-398 Copyright B 2017 Wolters Kluwer Health, Inc. All rights reserved.

T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N

System-Level Shared Governance Structures and Processes in Healthcare Systems With MagnetA-Designated Hospitals A Descriptive Study

Carlisa M. Underwood, DNP, RN

Arlene N. Hayne, PhD, RN

OBJECTIVE: The purpose was to identify and describe structures and processes of best practices for system-level shared governance in healthcare systems. BACKGROUND: Currently, more than 64.6% of US community hospitals are part of a system. System chief nurse executives (SCNEs) are challenged to establish leadership structures and processes that effectively and efficiently disseminate best practices for patients and staff across complex organizations, geographically dispersed locations, and populations. METHODS: Eleven US healthcare SCNEs from the American Nurses Credentialing Center_s repository of MagnetA-designated facilities participated in a 35-multiquestion interview based on Kanter_s Theory of Organizational Empowerment. RESULTS: Most SCNEs reported the presence of more than 50% of the empowerment structures and processes in system-level shared governance. CONCLUSIONS: Despite the difficulties and com- plexities of growing health systems, SCNEs have

replicated empowerment characteristics of hospital shared governance structures and processes at the system level.

Hospital consolidation has increased dramatically because of competitive markets, new regulations, and changing reimbursement structures. This reconfigu- ration of entities has led to the creation of new roles for system chief nurse executives (SCNEs).1-3 In this evolving role, SCNEs are faced with changing long- standing cultures, addressing inefficient clinical and operational services, creating systems to accommodate varying mandates, and managing the growing costs and accountability across widespread multi-healthcare sites.2,3 System CNEs, who have a track record of leading local entities as chief nursing officers (CNOs), are now relying on their leadership skills to leverage services on a lateral level, often across states. How- ever, these dynamics are complex. System CNEs are challenged to cultivate an empowering practice envi- ronment for the local and regional CNOs_ role within integrated health systems and shape strategic, opera- tional, resource, clinical, and professional practice outcomes in a larger platform.

The concept of shared governance (SG) is fre- quently viewed as sharing power at all levels of nursing with a goal to increase empowerment and improve practice, well documented at the hospital level.4-6 The structures and processes associated with establishing, hardwiring, and evaluating SG at a system level are less reported. There is also a paucity

396 JONA � Vol. 47, No. 7/8 � July/August 2017

Author Affiliations: Part-time Faculty, College of Nursing, University of South Alabama, Mobile (Dr Underwood); and Professor, Ida V. Moffett School of Nursing, Samford University, Birmingham, Alabama (Dr Hayne).

The authors declare no conflicts of interest. Correspondence: Dr Underwood, 16385 Gangplank Ln,

Woodbridge, VA 22191 ([email protected]). Supplemental digital content is available for this article. Direct

URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal_s Web site (www.jonajournal.com).

DOI: 10.1097/NNA.0000000000000502

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

of evidence to provide SCNEs guidance regarding working infrastructures and operational strategies in developing a system-level SG model while being cogni- zant to the need for point-of-service empowerment.

Objectives

The descriptive study was designed (1) to categorize the system-level, nursing decision-making model_s structures and processes according to SG, participa- tion, and Kanter_s7,8 empowerment concepts and (2) to identify and describe strategies of system-level SG structures and processes as reported by SCNEs.

Methodology

Sample

Using the American Nurses Credentialing Center_s repository of MagnetA-designated facilities, 422 facil- ities were grouped by parent-system affiliation, quanti- fied by total number of designated hospitals, and categorized by single-state and multistate span of control. A nonrandom sampling technique was used to identify the healthcare systems. An SCNE, or equiva- lent, of a healthcare system in the United States with at least 4 Magnet-designated entities before January 1, 2015, served as the inclusion criteria. After institutional review board approval from Samford University, 11 SCNEs of the 32 US healthcare systems initially identified as meeting the criteria consented to partici- pate in a 45-minute telephone interview conducted mid-October 2015 to mid-February 2016.

Instrument

Kanter_s7,8 Theory of Organizational Empowerment concepts and the review of literature on SG structures and processes framed a 35-multiquestion survey instru- ment examined by 2 subject matter experts. Kanter7,8

hypothesized that organizational practices and char- acteristics influence an individual_s attitude and per- formance within the organization and were linked to 3 principles: structure of relative numbers, structure of opportunity, and structures of power. The structure of relative numbers suggests that a balanced representa- tion of a group influences the perception of access to structures of opportunity and power. The structure of opportunity assumes that professional advancement, growth, and challenge lead to human responses such as aspiration for responsibility, organizational involve- ment, and commitment. Structures of power, informal (eg, casual work relationships) and formal (eg, highly visible networks), nurture behaviors such as coop- eration, control over practice, and autonomy. Infor- mal and formal powers reinforce an awareness of the organization_s practices via access to information, resources, support, and opportunity.

Results

A total of 11 health system (5 multistate, 6 single-state, all not-for-profit) SCNEs participated in the study. Among health systems that identified as multistate, the span of control ranged from 2 to 21 states and from 4 to 105 hospitals. Respectively, single-state systems ranged from 4 to 26 hospitals. Magnet facilities within the systems ranged from 8.8% to 100%.

System SG Structures and Processes

Well-constructed structures and processes that define and regulate system-level SG frame the context for CNOs_ empowerment. Mergers and acquisitions have changed the landscape of healthcare leadership.2

System-level nurse executives must create support structures, including SG, to standardize care across care settings.2,9 In this study, SCNEs conducted eval- uations of the system structure between 6 months and 3 years post implementation or restructuring. System CNEs who conducted a formalized evaluation reported instituting a plan of action linked to the assessment. Regardless of evaluation type, instruments used to guide SCNEs_ efforts included Haven_s Decisional Involvement Scale,10 the nurse executive dashboard,11

the Magnet model,12 Porter-O_Grady_s13 framework, Kanter_s7,8 theory, and the system_s professional prac- tice model (see Table, Supplemental Digital Content 1, http://links.lww.com/JONA/A539).

Access to Information and Resources

Information and resources facilitate efficiency, effec- tiveness, and transparency of system-level decision making. The SCNE"s corporate office, the system- level SG department, the local CNOs_ facilities, and the SCNEs’ and CNOs_ sharing of expenditures served as a source of funding to assist primarily with travel, meeting, and lodging expenses. Most SCNEs reported accessing subject matter expertise to include inter- nal and external consultants and an in-house, virtual nursing excellence team to assist CNOs with system- level SG tasks. In addition, secretarial support was essential in facilitating communication. Minutes were reported to be in standardized templates and circu- lated immediately after meetings as a best practice (see Tables, Supplemental Digital Content 2, http:// links.lww.com/JONA/A540, and Supplemental Digital Content 3, http://links.lww.com/JONA/A541).

Role of the Entity CNOs in System-Level SG

The entity CNOs played critical leadership roles in representing the needs of stakeholders at the corpo- rate table. System CNEs supported CNOs_ commit- ment for active participation in the corporate structure through 3 key strategies: (1) instilling a culture of

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

expectations and common interests among the local and regional facilities, (2) encouraging CNOs_ participa- tion in system and national leadership opportunities, and (3) designating CNOs as mentors to guide newly assigned system SG members. In addition, the use of communication platforms, with interactive audiovi- sual capabilities, created real-time connections among geographically dispersed CNOs for meetings and up- dates (see Tables, Supplemental Digital Content 4, http://links.lww.com/JONA/A542, and Supplemental Digital Content 5, http://links.lww.com/JONA/A543).

Refined structures and processes for input and decision making provided CNOs with a venue for involvement in a system-level SG model. A locus of control at the system level including advance scheduled council meetings, a representative membership, and a culture of standardization and unity in decision making supports partnership and engagement of entity CNOs. Identified barriers to participation of entity CNOs include (1) CNOs balancing participation in SG with the needs of the local entities_ operations and (2) dis- sention in the decision-making process due to CNOs_ reluctance to change embedded practices at the local sites (see Table, Supplemental Digital Content 6, http:// links.lww.com/JONA/A544).

Conclusions

Organizational empowerment at the system level is maximized when opportunity, information, resources, and support are strategically developed and managed as indicated by most SCNEs surveyed (91%, n = 10).

Subsequently, the greater part of the SCNEs in this study perceived access to empowering elements influencing the local and regional CNOs_ participa- tion in system-level SG (see Table, Supplemental Digi- tal Content 7, http://links.lww.com/JONA/A545). There are many factors that impact organizational empowerment on a system level including report- ing relationships between the SCNE and the entity CNOs, collaborative work agreements, SG models at the local level, and system growth and expansion.

The descriptive study generated evidence of the system-level SG structures and processes currently in place in systems containing Magnet-designated hos- pitals. The evidence revealed patterns of organiza- tional structures and processes central to Kanter_s7,8

Theory of Organizational Empowerment at the system level. System CNEs_ continued collaboration with CNOs and investment in developing and facilitating access to information, resources, support, and opportunity within system-level SG have implications for the local and regional CNOs_ participation. Further research is indicated to explore in more depth the structures and processes of system-level models, the role of nursing leaders, and the associated clinical and organizational outcomes.

Acknowledgments

The authors thank Dr Carol J. Ratcliffe for exper- tise during survey development, Dr Joan Shinkus Clark for editorial input, and all survey partici- pants for insightful responses.

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398 JONA � Vol. 47, No. 7/8 � July/August 2017

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.