These slides are uploaded for information purposes and as a partial requirements of Philippine Women's University in PhD class. Subject : Governance in Health Care Practice

1. Shared Governance: integrating nurses
towards excellence
Arce Vete Amparo, RN, MAN
Reviewed by: Dr. David Hali De Jesus

2. Disclosure
The Author has no financial closure or
conflicts of interest with the presented
material in this presentation.

3. Learning Outcomes
At the end of this presentation, the readers
will be able to:
• Outline and cognize the concepts of the
following:
1. Shared Governance
2. Shared Governance in Nursing.
• Recognize the principles of shared
governance, its pros and cons.
• Execute shared governance in a nursing
organization.

4. Introduction
“Nursing is the protection,
promotion, and optimization of
health and abilities, prevention of
illness and injury, alleviation of
suffering through the diagnosis and
treatment of human response, and
advocacy in the care of individuals,
families, communities, and
populations.” —American Nurses
Association (2003)

5. An empowering organizational model that
creates a structure for shared decision-
making in the clinical care of patients.
When granting Magnet Recognition and
Pathway to Excellence Program designations,
the American Nurses Credentialing
Center considers how well the principles
Of shared governance are implemented
throughout an organization.

6. Shared Governance in Nursing
• Shared governance is shared decision-making based
on the principles of partnership, equity,
accountability, and ownership at the point of service.
• This management process model empowers all
members of the healthcare workforce to have a voice
in decision-making, thus encouraging diverse and
creative input that will help advance the business and
healthcare missions of the organization.
• In essence, it makes every employee feel like he or
she is “part manager” with a personal stake in the
success of the organization.

7. Shared Governance in Nursing

8. Effective Shared Governance leads to:
Improved patient care and safety.
Decreased hospital lengths of stay.
Improved patient satisfaction
Empowered nurses
Improved nurse satisfaction.
Engagement and synergy among members
of a healthcare team
Increased nurse retention.

9. Shared Governance- A Brief History
The concepts of shared governance and shared decision-
making are not new. Philosophy, education, religion,
politics, business and management, and healthcare have all
benefited from a variety of shared governance process
models implemented in many diverse and creative ways
across generations and cultures
• Socrates (470-399 BC) The Socratic Method (answering a
question with a question) calls for the teacher to
facilitate the student's autonomous learning as the
teacher guides him or her through a series of questions.
The Socratic Method encourages students to use reason
rather than appeal to authority.

10. Shared Governance- A Brief History
• Government: European Union and the United Nations decision making model includes
participation from individual member countries.
• Business: Apple and Google actively engage with frontline teams in the decision making
process. Multiple fortune 500 companies have moved decision making from the
traditional hierarchical approach to the point of service outward.
• Healthcare: In the late ‘70’s participative management was emerging as nurses grew
dissatisfied with the institutions they practiced in.

11. Shared Governance- A Brief History
Christman (1976)
• Introduced the autonomous nursing organization concept
• Equal voice with physicians within hospitals
Cleland (1978)
• Introduced label of shared governance
• Model reconciled the interests of different organizational
groups through the distribution of power to formulate policy
• Soared in the 1980’s due to the infusion of humanizing
models.
• Original concepts morphed to fit health care institutions

12. Contributing Factors Towards Shared Governance
 In the 19XXs, shared governance found its way into the business and management
literature (O’May and Buchan 1999; Laschinger 1996; Peters 1991; Walton 1986;
Peters and Waterman 1982). Organizations began to design structures and
relationships among their leaders and employees. They emphasized making decisions
from the point of service on instead of from the organization downward.
 In the late 1970s and early 1980s, shared governance formally found its way into the
healthcare and nursing arenas, growing out of nurses’ dissatisfaction with the
institutions in which they practiced (O’May and Buchan 1999; Porter-O’Grady 1995;
McDonagh et al 1989; Cleland 1978). They started to use it as a form of participative
management, using self-managed work teams.

13. Contributing Factors Towards Shared Governance
 Deming (1986), introduced new concepts of quality management, proposed that an
organization’s work environment value quality, empower the worker to be more
productive, and emphasize leadership and team building. Forms of shared
governance appeared that were formed in alliance with an organization’s quality
management initiatives (Gardner & Cummings, 1994; Thrasher et al., 1992).
 Kanter (1977, 1993) suggest that formal and informal power permit access to work
empowerment structures (opportunity, resources, support, and information) that
enable workers to accomplish their work. Being empowered suggests a model of
shared governance where decisions are made at the point of service (Porter-O’Grady,
1995).

14. Growing needs in Shared Governance
 Framework of shared governance applied on a patient care level
is one manner appealed to improve delivery of quality care
(McDonagh et al., 1989).
 Nursing shortages offer often cited reasons including a lack of
autonomy in practice, low pay, poor prestige, and poor working
conditions (Deremo, 1989), to which a major contributing factor
may be the highly bureaucratic structures of hospitals. Shared
governance, operating within a professional practice framework, is
apply for to address the administration and practice factors
contributing to these shortcomings (Dennis, 1991). Shared
governance has been offered as a solution to the perceived
problem of bureaucracy, by enabling nurses to assume
responsibility for and authority over their practice (Porter-O'Grady,
1987).

15. Growing needs in Shared Governance
 Stott and Walker (1995) argue that self managed work teams are
an emerging trend in many organisations, and are often associated
with the term `empowerment'. Certainly, as a response to
escalating problems of pricing and management constraints, co-
operative and democratic teamwork would seem to offer one way
of attempting to reduce costs and increase cohesiveness and
autonomy.
``Shared governance has been credited with being the answer to
retention, nursing shortages, advancing the nursing profession,
and expanding nurses' autonomy for their practice and work life‘’
(Rose and Reynolds, 1995, p. 1).

16. Action towards Shared Governance
The ‘Four Is’
•Idealised influence: establishing a sense of purpose,
focusing on individual beliefs and values;
•Inspirational motivation: goal setting, visionary
behaviour, encouraging others;
•Intellectual stimulation: encouraging critical thinking,
creativity and analysis of new perspectives; and
•Individual consideration: concern for the individual’s
need for achievement and growth, focus on individual
behaviour (Sarros & Butchatsky 1996, p. 6).

17. Four Principles of Shared Governance
PARTNERSHIP
Emphasis on teamwork among nurses, healthcare providers and
their patients
OWNERSHIP
Each team member owns his or her contributions to healthcare
decision-making
EQUITY
Equal focus on services, patients and staff because each is
essential in providing safe and effective care.
ACCOUNTABILITY
Considered the core of shared governance, it is the willingness
to take responsibility for decision-making.

18. Governance Model
The Whole-Systems Governance
- New term for a system that unites all professionals involved in the care delivery process -- nurses, other
clinical disciplines, physicians, and administrators -- under a structure that integrates clinical, support,
and organizational concerns across traditional boundaries.
- Nursing support provides an opportunity for the organization to integrate everyone's growth in shared
governance. Healthcare can only manage to change strategically if the whole organization joins nursing's
efforts and they collectively undertake the necessary structures for change together. Shared governance
needs to be incorporated so that it becomes an organizational imperative and continues to grow across
the organization.
- All employees play a role in the organization as a whole, participating as part of the organization in the
directions, policies, decisions, and objectives that set the organization on a course for its own future.
Nursing has an opportunity to lead their respective organizations into that future through shared
governance.

19. Governance Model
Nurse- Shared Governance
- This innovative organizational model gives staff nurses control over their practice and can extend their
influence into administrative areas previously controlled only by managers.
- Nursing practice councils allow nurses to take a primary role in clinical practice decisions and
implementation of evidence‐based practice (Erickson et al . 2008). Councils in a community hospital
matched the mission of the council with goals of nursing service to provide excellence in best practice.
- The means of exercising power is through nursing practice councils, developing trust in management,
while also developing facilitation and problem solving skills.

20. Governance Model
Professional- Shared Governance
- It reflects an understanding that the needs and requisites of effectively governing a profession are
specifically and significantly different from those that affect an employee workgroup.
- Three fundamental principles both affirm and validate the presence of effective and sustainable nursing
professional governance structures and practices:
1. Professional governance is grounded in practicing nurse accountability;
- demonstrate personal accountability for owner-ship of the work.
2. Structures are built around professional accountability and clinical decision-making;
-responsible for management-specified and directed functions and activities, and
managers are accountable for the products of work; it’s believed that this distribution of
authority and work is aligned in a way that advances efficiency and productivity
3. Professional governance structures reflect distributive decision-making.
-organized around decisions, not positions, reflecting the distribution of accountability for those
authorities that are unique to the profession.

21. Advantages of Shared Governance
- It fosters inclusiveness and diversity.
Constituents may provide a wide diverse variety of information and ideas.
Policy alternatives and new ideas and approaches may be identified.
- It fosters ‘buy in”
If constituents are included in the policy and implementation process, they
are more likely to support decisions.
- It identifies potential problems
It constituents are allowed to oppose potential policies and decisions,
managers and administrators can identify problems and prepare strategies
and responses in advance of policy decisions

22. Disadvantages of Shared Governance
- Inefficient
Consultation with members and consideration of alternatives requires a lot
of time and it also considerably lengthens implementation of policies.
- Divisive
Discussions may create diverse idea that may lead to conflicts
- Undercuts privacy and secrecy
Issues amongst personnel and negotiation about policies may be
prematurely revealed during discussions
-Chaotic
Unexpected issues that may alter plans and procedures can arise at anytime
-Arbitrary
Everyone cannot be included all the time. Sometimes, debates need to end
to make a decision, that could make other members feel left out or ignored.

23. Implementation of Shared Governance
Governance Structures
Porter-O’Grady (1987) outlined three professional governance structures
that can be employed in practice settings: (a) councilor, utilizes councils to
manage processes and decision-making; (b) congressional, with elected
officers and cabinet members overseeing operations; and (c) administrative,
with authority divided between clinical staff and administrative functions.
Porter-O’Grady (2001) describes the stages of implementing the structure of
shared governance as three-fold; making the needed changes in persons
and in the system itself, then changing the structure to support the new
process of decision-making, and finally reinforcing the new patterns.
Planning for implementation needs to include an assessment of the
supporting structures in order to increase the effectiveness of the shared
governance model chosen and the success of the initial councils.

24. Implementation of Shared Governance
Nurse Outcomes
The implementation of shared governance or the designation as a magnet
hospital have been used as independent variables in a number of studies to
determine the organizational model’s effect on nurse, patient and
organizational outcomes.
Measured outcomes involving the nurse include burnout rates, job
satisfaction, likelihood of leaving the organization, perceived control over
practice, autonomy, and perception of their mental health.
Retention of nursing staff in the current environment was the driving force
behind implementing an organizational model that fosters improvement in
nurses’ mental health, burnout rates, job satisfaction, autonomy,
empowerment and control over professional practice.

25. Implementation of Shared Governance
Patient Outcomes
Access to empowerment structures and a supportive professional practice
environment were significantly linked to the patient safety climate in a study
with 153 nurse respondents in Magnet hospitals (Armstrong et al., 2009).
In a comparison of work environments in a large healthcare organization,
employees who perceived their work climate to be participative as opposed
to authoritarian provided 14% better customer service and committed 26%
fewer medication errors (Angermeier, Dunford, Boss, & Boss, 2009).
Improved patient outcomes have been reported for facilities that have
achieved Magnet Recognition from the American Nurses Credentialing
Center (ANCC). Aiken (1994) studied 39 magnet hospitals and 195 control
hospitals with regards to Medicare mortality rates as a patient outcome.

26. Implementation of Shared Governance
It’s crucial that staff be encouraged and allowed time away from patient
care activities to participate in decisions that affect their practice.
According to Hoying and Allen (2011), enhancing shared governance never
ends. Shared governance is difficult to implement due to the time
commitment, the culture change that must occur, and the education needed
by staff and nurse leaders. Shared governance must be evaluated, revised,
and supported on an on-going basis.
Nurse leaders play a pivotal role in creating and sustaining a professional
work environment that promotes autonomy, empowerment and nursing
satisfaction (Barden, Griffin, Donahue, & Fitzpatrick, 2011).
Staff nurses must be knowledgeable about the philosophy of shared
governance and how it can improve and enhance their practice. They must
be able to connect that philosophy to the values and mission of the
organization.
Is
there a
best
way?

27. “An attitude of accountability lies
at the core of any effort to improve
quality, satisfy customers,
empower people, build teams,
create new products, maximize
effectiveness, and get results.“
- Tom Smith

28. References:
• https://consultqd.clevelandclinic.org/so-what-is-shared-governance-a-quick-guide/
• https://www.summahealth.org/supportservices/nursingservices/shared-governance
• Swihart, D. 2011. Shared Governacne: A practical approach to transforming professional nursing
practice. 2nd edition, HCPro, Inc Philadelphia
• https://www.researchgate.net/publication/12895624_Shared_governance_A_literature_review
• http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofCont
ents/Volume92004/No1Jan04/SharedGovernanceModels.html
• https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2834.2010.01134.x
• http://eds.a.ebscohost.com/eds/detail/detail?vid=0&sid=bb911f13-471f-4c25-be10-
0c6fb9f0eb35%40sdc-v-
sessmgr01&bdata=JkF1dGhUeXBlPXNzbyZzaXRlPWVkcy1saXZl#AN=16508324&db=asx
• https://onlinelibrary.wiley.com/doi/full/10.1111/jonm.12032
• https://corescholar.libraries.wright.edu/cgi/viewcontent.cgi?article=1014&context=nursing_dnp

29. Note:
These slides are uploaded for information purposes and as a partial
requirement of Philippine Women's University in Ph.D. class;
Subject: Governance in Health Care Practice.