Shared governance (SG) is a nursing practice model that is a cornerstone of professional practice and the pursuit of Magnet designation from the American Nurses Credentialing Center.1 Often referred to as shared leadership or team management, SG is based on the principles of partnership, equity, accountability, and ownership.1-3 Hess4 defined the SG process as "a multidimensional concept that encompasses the structure and process in which organizational participants direct, control, and regulate the many goal-oriented efforts of other members." The idea of SG, although appealing, is often easier to describe than implement, disseminate, and enculturate. Processes and structures have been described, but maintaining a viable, active system and measuring outcomes can be difficult.2
Working for 20 years in a community hospital system, I have seen patterns of success and breakdown over the course of implementation, evolution, and continuation of the SG process. The processes of SG wax and wane as members and organizational imperatives change. There is a cadre of factors that facilitate and hinder the success of SG processes (Figure 1). Evolution and maintenance of SG require ongoing nurturance and attention to processes supporting success or leading to breakdown. The purpose of this article is to summarize those factors. Shared governance is used as a generic term referring to the various forms that have developed since initial development in the 1980s.
The success or breakdown of SG is based on complex interactions at the unit level, the hospital level, or hospital system level. Understanding that SG is a process, not just a project, with a one-size-fits-all template guaranteeing success is an important foundational concept. Several factors are posited to be the cornerstones of successful programs. These factors include leadership support, role delineation, processes for decision making, clear vision, communication plans, education, managerial support, and supported time to participate.2,5,6 Factors contributing to breakdown are poor understanding, poor support structure, lack of education, lack of follow-through, inadequate resources, and poor communication.3,6,7
Factors Leading to Success
Human factors science studies the impact of human capabilities and limitations on processes that range from education to technical skills.8 Most commonly, human factors science has focused on the impact on safety events to prevent recurrence. Human factors also play a part in success or breakdown in processes that are conceptual, like SG. Successful communication of a vision by senior nursing leaders, along with support of nurse managers, is important to the change in practice patterns from authoritative to shared decision making. Design input by nursing leadership, nurse managers, and staff nurses of the model for SG that delineates authority and accountability is essential to continue the development after initiation of a structure.5 Kennerly,9 in a study on SG, challenged the often stated fact that SG was responsible for improved perception of personal autonomy. In contrast to this often stated fact, Kennerly9 stated that moderate to high levels of autonomy need to be present to support development of SG rather than autonomy developing as an outcome of SG. Tools that may be used to measure readiness or progression of SG are provided in Table 1. Although the idea of whether SG promotes autonomy versus autonomy supports SG needs further research, the goal of SG is support for decision-making authority about professional practice by the nurses providing the care. Providing the vision, engaging nurses at all levels, and communicating positive expectations are important human factors for success.
First-line nurse managers have a pivotal role in the success of unit-based councils. As noted by several authors, the transition to coach and staff mentor while giving up comfortable authority patterns can be difficult. Managers often have the steepest learning curve in the new process.5,10-13 A great structure alone will not produce the change in attitude and culture that is the goal of SG. Use of a transitions team, well educated in the SG structure, as a strategy was identified in 1 successful program.10 The transition team worked with the initial start-up of SG then continued to mentor flagging councils. Communication that all decisions may not be perfect is important for both managers and staff to understand. Preparation of managers well in advance of implementation is important to success. Providing scenarios along with potential action and communication strategies for managers can be helpful as managers struggle to transition to the new shared leadership role.
Apathy of staff is often stated as a barrier to success. From the literature, as well as my personal experience, engagement of both formal and informal leaders in early development improves likelihood of success.6,13,14 If informal leaders are not interested in serving as a council member, seeking input from these key leaders and engaging them in activity such as solicitation of peer opinion or reviewing the literature provide opportunity for staff unable to serve on the councils to be involved.9 Acceptance of each staff member's ability to contribute is important to success.15
Structural factors include role identification, support processes, decision structure, scheduling, and education. Mentoring of managers should precede the implementation of formal processes to provide the necessary support for staff nurses.6,10 Data important to decision making should be identified along with mechanisms to obtain data formatted for ease of use by staff. A process for regular reporting is important in promoting staff appreciation of accountability for outcomes and quality. Staff who are elected, appointed, or invited to represent their peers on the unit-based and hospital councils need to be educated and supported to assume new roles. Hesitancy about exactly what and how to accomplish the work of governance is expected. How to develop an agenda, run a meeting, shepherd discussion, and reach consensus are all learned skills that may need coaching. Time spent in preparation for these roles can make or break a successful council.
Education on how to read and interpret the various reports used to understand the practice environment is essential to good decision making by SG councils. Do not assume that all nurses have acquired these skills. Providing baseline instruction on the identified skills assures that all staff can play an active role in analyzing the data. Development of a toolkit to address all of these factors is part of an ongoing plan in my institution to support decision making. Planning for gradual transition of the work of the unit/division/hospital will make this transition of governance easier. Delineation of the structures and roles of managers, council members, and staff is important to avoid role confusion.
Even with good education and planning, it takes time and trial and error to be successful. Ongoing education related to structure and roles needs to be available as managers, staff, and council members change. A nurse manager in my institution, 4 years into a restructured SG process, stated it well, "SG can be compared to a piece of art or a picture, where each member of the team, makes up the image of the picture and the leader is the frame that provides support, direction and guidance as well as the boundaries if needed. SG is truly staff driven and staff ownership…. After this education, the first meeting came as well as the challenges. The staff wanted to change everything that they did not like about our unit as well as the hospital. They (the unit based council) wanted to change the things they had control over as well as the things they had no control over…. Four years later, we have developed into a very strong unit, as well as I have developed into a better leader because of the staff engagement with SG." At present on this unit, a high percentage of staff are currently engaged in SG and can provide a list of accomplishments and current projects.
In all complex organizations, there are boundaries within which a group has total control over decisions, larger boundaries in which influential input is provided, and organizational boundaries driven by administrative constraints that cannot be changed by SG processes. Initial identification of the spheres of council influence and decision making is important to prevent frustration or sense of failure of the SG process. Understanding how to substantiate need for changes, the timing of requests, and how to initiate changes is an important piece of evolutionary development of councils for large-scale change. Nursing leaders from the executive to the manager level are instrumental in identifying the boundaries of decision authority by each level of the councilor structure. Clinical specialist or other advanced practice nurses can be used to mentor staff in the identification of evidence to support identified need for change. The manager plays a key role in guiding topics for consideration and proposed actions at the unit-based council level. Initially, setting standards for meeting format and clearly defining the limits in place for new councils prevent subsequent frustration from tackling large-scale change that requires longer time frames and political maneuvering. Suggested initial guidelines for structure include the following:
* Must be congruent with hospital policies and procedures.
* Proposed changes must improve patient care/quality outcomes/ work environment.
* Financial outcome must be budget neutral or justified.5
Reaching a self-sustaining level of governance takes work and persistence as new roles are adopted and comfort levels are achieved.
Communication structures between councils, nursing leadership, staff, and related departments need to be identified and followed using multiple modes of communication. Solicitation of peer feedback and communication of actions as well as outcomes are necessary for enculturation of the SG system as a viable process for professional practice. Lack of communication is an often mentioned negative factor in evaluations of SG processes.5,10,13-15
Support for staff to attend meetings needs to be provided and attendance established as an expectation by the nursing leadership team. Budgetary processes that separate meeting time into a trackable account should be developed to account for the time used outside of the unit budget for direct care nursing hours to avoid budget constraints as an influencer on support for attendance. Time attributed to SG can then be tracked along with outcomes achieved. Follow through on decisions by managers supporting unit-based council's decisions, and nursing leadership, for hospital council's decision, must occur for staff to see success related to decisions. Enthusiasm for SG will quickly wither if only token decisions are made or required action does not follow decisions.3,5,10,12,14 Celebration of each success should be used to further empower staff in this expanded role in establishing a professional practice environment. Shared governance is a journey with ongoing need for investment in human capital, education, meeting support, and financial planning.
Factors Contributing to Breakdown and Strategies to Prevent Breakdown
Why does SG flourish on some units and flounder on others? Little research has been done on this topic, but several actions can be inferred from personal experience, discussion with colleagues, and the literature (Figure 1). Role confusion, lack of support, lack of recognition, and staff apathy are the most often reported barriers.6 One organization identified an annual evaluation of the SG process with revision when needed as an effective strategy facilitating success.14 As practice evolves and staff nurse leaders mature, the roles of managers and councils should be revised to recognize and promote continued growth. Providing more authority and accountability for SG decision-making groups and eliminating constraints to decision making should be the goal of nursing leadership for SG evolution into a mature professional governance model.
Lack of data to support decision making can lead to poor decisions. Identification of data sources and tools to aid decision making such as practice change algorithms, literature search support with librarians or advanced practice nurses, and leadership development and mentoring are all strategies that support council decision making. Consultation with appropriate knowledge experts from within an organization facilitates good council decisions and results in interdisciplinary awareness of SG authority. Actual and perceived power is important to the success of SG within a larger organization.7 Use of financial consultants or experienced nurse executives to analyze and provide costs/savings provides important information that serves to both educate staff and support decision making.
Failure of leadership to support meeting and project time via budget planning sends the message that the process is unimportant. Analysis of needed time and accountability to use the time productively with identified outcomes is important to viability within the organization. Providing recognition of contributions for the work that is done demonstrates value for the process. Publication in hospital newsletters and having staff nurses present the outcomes and successful projects hospital wide or at executive meetings are successful strategies I have seen that send the message that the work is significant and valued.
Staff apathy is always a potential problem to a successful SG system.2,3,5,6,10,12,16,17 A small nucleus of enthusiastic council members who meet regularly and engage peers in projects, along with small successes, can impact staff attitude and willingness to serve. One organization noted positive staff perceptions when more than 50% of staff were involved in unit governance and meetings occurred regularly.5 Nursing leadership support and recognition of efforts builds staff confidence that SG is more than a token effort.7 As council members and the nurse manager become comfortable with the shift in authority and accountability to a governance process for decision making, decisions related to practice, care delivery model, unit budget, and educational needs can become the province of the SG council. The manager's role becomes more of a coach and facilitator.10,14
To gauge the need for preliminary work before initiating an SG structure, evaluation of staff's perception of self-governance may be useful.4 There are several available tools (Table 1) to measure readiness and progression of SG and shared decision making. When unit staff, managers, or new council members are struggling, a program of ongoing education and consultative assistance has shown some success in fostering SG development.5,10 As Brook18 noted, the easiest part is development of a structure, the hard part is the change in attitude and role.
Lack of understanding and "buy-in" by first-line managers will prevent a new SG structure from developing past the first bloom of excitement. Providing a nurse manager support group to share successes and role modeling, although not found in the literature, is proposed as a strategy for building a strong SG practice model. I have found providing refresher education on the SG structure, along with presentations by successful unit managers and council members, as a positive strategy to rekindle enthusiasm in units where SG is flagging. Stories by successful peers provide a powerful message that supports enculturation of the processes. Based on the response from nurse managers to this initiative, an ongoing forum for support of managers has been implemented as part of nursing leadership meetings.
Potential barriers and proposed strategies have been identified to support the development and propagation of SG from both the literature and personal experience. Although SG is not a panacea for curing all ills, it is an essential process that supports the objective of a professional work environment. As O'Grady noted, "Magnet facilities achieve designation due to the practice that is supported by the framework (SG), not due to the framework."1(p252) Shared governance as a framework for practice continues to evolve new iterations that are dynamic with hospitals at different stages of the continuum of mature SG processes.2 In response to a query regarding the continued relevance of SG, O'Grady19 reiterated that the principles of SG processes in the current healthcare climate are relevant for pursuit of optimal practice environments.
There are excellent resources with detailed information on strategies related to SG implementation. Complete guidelines for SG development and implementation are beyond the scope of this article but are available at 2 excellent Web sites, www.tpogassociates.com/SharedGovernance and www.sharedgovernance.org. Careful planning and nurturing, considering human and structural factors, can make a difference in the success or breakdown of SG initiatives.
© 2010 Lippincott Williams & Wilkins, Inc.