Clavelle, Joanne T. DNP, RN, NEA-BC, FACHE; O’Grady, Tim Porter DM, EdD, APRN, NEA-BC, FAAN; Drenkard, Karen PhD, RN, NEA-BC, FAAN
Chief nursing officers (CNOs) have senior-level organizational authority for creating a dynamic nursing practice environment (NPE) through nursing shared governance (SG).1-3 The American Nurse’s Credentialing Center (ANCC) Magnet Recognition Program® places considerable emphasis upon the role of the CNO as transformational leader supporting a flat, flexible, and decentralized organization in the model component of structural empowerment.4,5 Recent evidence identifies “enabling others to act” as the top transformational leadership practice of Magnet® CNOs.6 There is little recent literature regarding the characteristics of SG in Magnet organizations and relationship to the NPE.
Review of the Literature
Kanter’s7 theory of structural determinants of power outlines how work structures empower employees by improving access to information, support, resources, and the opportunity to learn and develop. In Magnet organizations, the implementation of SG is a common work structure implemented to support nursing professional engagement, role development, professional development, recognition, and community involvement.4,8-11
The concept of SG originated more than 30 years ago, with Porter O’Grady and Finnegan describing a nonhierarchical organizational structure for nursing and organizational interdependence.12,13 This “point of service empowerment”13(p87) creates a “structural “glue” that enables the profession of nursing to come together in both purpose and discipline,14(p45) balancing power between management and staff. Within this construct, a matrix of councils with authority and accountability for professional practice and decision making work interdependently with organizational leadership and authority to achieve desired outcomes.12,13 Nurse control over practice is legitimized15 and valued,16 enabling them to make decisions and assume accountability at the point of care guided by 4 principles: partnership, equity, accountability, and ownership.13
In the model component of structural empowerment, Magnet organizations must demonstrate how nurses throughout the organization are involved in self-governance and decision-making structures and processes that impact professional engagement, supporting nursing empowerment and autonomous practice.4 Nursing empowerment positively impacts autonomy,17,18 practice,17,19-21 job satisfaction,17,19,22 nurse-physician relationships,17 patient care quality,19 and participation in SG.22,23 Autonomous nursing practice has a positive impact upon work effectiveness,18 nursing turnover, and patient satisfaction.24 As nursing leaders work to improve the engagement of nurses in improving patient care quality and experience, a structure that has been effective is SG with nurses at the clinical level/bedside. Although the literature supports improved outcomes when clinical nurses participate in shared decision making, the characteristics and outcomes of SG in healthcare organizations have not been extensively studied.
The purposes of this study were to probe structural empowerment in Magnet organizations, describe the characteristics of both SG and the NPE, and explore any relationships between them and with organizational outcomes.
Design and Research Questions
The study was a national descriptive study with level II correlational design. The research questions were the following:
* What are the characteristics of nursing SG in Magnet organizations?
* What are the characteristics of the professional NPE in Magnet organizations?
* In Magnet organizations, is there a relationship between nursing SG, the professional practice environment, and organizational outcomes?
The sampling frame consisted of 344 organizations in the United States holding ANCC Magnet designation as of June 1, 2012. The populations sampled from each organization included the Magnet CNO and a chairperson of their organizational NPC. The final sample size consisted of 95 CNOs (27.6%) and 107 NPC chairs (31.1%) of the 344 potential organizations invited to participate in this study. Exclusion criteria were (1) any Magnet organization earning initial designation after June 1, 2012, and (2) any Magnet organizations outside the United States. The protocol for the study was approved by the St. Luke’s Health System institutional review board. The survey period began September 1, 2012, and ended December 31, 2012.
A listing of all Magnet organizations as of June 1, 2012, along with the e-mail address of all CNOs, was requested by the principal investigator (PI) from the ANCC Magnet Recognition Program. To minimize the risk of connecting a response to a specific individual or organization, the PI hired a research assistant (RA) to sort and alphabetize the list, remove international organizations, assign each organization a number, create a separate e-mailbox, collect responses from CNOs agreeing to participate, facilitate e-mail communications and reminders, access data collected, and generate reports. The RA assigned a number to each participating organization and aligned the contact information of the NPC chair, provided by the CNO, with the CNO’s contact information. In August 2012, an invitation to participate went to the Magnet CNO listserv (n = 344), and agreeing participants were asked to provide the name and e-mail address of their organizational nursing practice chair. Reminder e-mails to participate were sent 1 and 3 weeks to the CNO listserv, followed by reminders to nonresponding CNOs monthly in September, October, and November. Only the chairs of the organizational practice councils were asked to complete the Index of Professional Nursing Governance (IPNG) and Nursing Work Index–Revised (NWI-R) tools in addition to their demographic information. Each CNO was asked to provide demographic and organizational information.
Data were collected via the Web-based SurveyMonkey platform and downloaded in Excel, pairing responses by organization. Collected data were downloaded into the Statistical Package for the Social Sciences (SPSS 18.0, Chicago, Illinois) software for analysis.
The IPNG is an 86-item instrument that measures perceptions of governance within organizations in 6 subscales: (1) control over personnel, (2) access to information, (3) resources supporting practice, (4) participation, (5) control over practice, and (6) goals and conflict resolution.15 Respondents identify the group that controls areas cited in the subscales on a 5-point scale, where 1 = nursing management/administration only, 2 = primarily nursing management/administration with some staff input, 3 = equally shared by staff nurses and nursing management/administration, 4 = primarily staff nurses with some nursing management/administration input, and 5 = staff nurses only. Governance distribution is distilled into 3 categories: traditional, shared, or self-governance.1,15,25,26 For this study, α reliability coefficients were .959 for the total instrument and between .839 and .908 for the individual subscales, summarized in Table 1.
The NWI-R measures characteristics of the nursing professional practice environment in 4 subscales: (1) autonomy, (2) control over practice, (3) nurse-physician relationship, and (4) organizational support.27,28 Nurses are asked to rate on a 4-point Likert-type scale their agreement that various elements of their NPE are present, with responses ranging from 4 = strongly disagree to 1 = strongly agree. The α reliability coefficients for this study were .93 for the total instrument and between .623 and .787 for the individual subscales, summarized in Table 2.
Variables analyzed included IPNG total scores, governance distribution, and individual subscale scores; NWI-R total and subscale scores; registered nurse (RN) full-time equivalents (FTEs); percentage of RNs with bachelors of science in nursing (BSN); RN vacancy rate; and RN turnover rate. Chief nursing officer variables included age, years as a CNO, and years in their current organization. Nursing practice chair variables included age and years as a RN.
Descriptive statistics, including means, ranges, standard deviations, and counts, were calculated for bed size, RN FTEs, % BSN, RN vacancy rate, RN turnover rate, and years as a Magnet organization and are summarized in Table 3. Chief nursing officer statistics included age, years as a CNO, and years in the organization; nursing practice council chair statistics included age and years as RN. Total score and subscales of the IPNG and NWI-R and associations between demographic variables and the IPNG and NWI-R total and subscale scores were assessed using independent-samples t tests, χ2 tests, and analysis of variance (ANOVA). Associations between the overall score on the IPNG and the NWI-R and between various subscales of the 2 instruments were evaluated using Pearson correlations. Analysis of the IPNG was analyzed based upon survey scoring guidelines provided with permission to use the survey. The mean NWI-R overall score and subscale scores were tested against the IPNG dominant controlling groups using ANOVA. Linear regression models were used to predict the overall NWI-R total and subscale scores based upon demographics and IPNG total and subscale scores and, similarly, to predict IPNG total and subscale scores based on demographics and the NWI-R score.
A total of 107 NPC chairs and 95 CNOs of Magnet organizations completed the survey, for a 31.1% and 27.6% response rate, respectively. Of the CNOs who answered the demographic questions, 85 were women (89.5%) and 10 were men (10.5%). Ninety-one of the NPC chair respondents to the gender question were women (98.1%) and 2 were men (1.9%). Mean organizational RN BSN percentage was 57.3%, with a mean RN vacancy rate of 3.89% and RN turnover rate of 8.4%. A summary of other characteristics of the organizations, CNOs, and NPC chairs is summarized in Table 3.
The governance distribution, identified by 81.9% of Magnet NPC chairs, was SG—primarily management/administration with some staff input (Table 4). The IPNG total and subscale SG ranges and means (Table 5) indicate total and subscale means for access to information, participation, resources supporting practice, control over practice, and goals and conflict resolution to be within the SG range. The IPNG subscale for control over personnel, however, was within the traditional governance range, with management/administration as the dominant controlling group. Ranges, means, and standard deviations for the total and each of the 4 subscales for the NWI-R score were calculated and are summarized in Table 6, with n = 96, and mean and standard deviation (SD) values of autonomy = 1.35 (0.385), control over practice = 1.48 (0.397), nurse-physician relationship = 1.42 (0.479), organizational support = 1.44 (0.351), and total score = 1.48 (0.284). To determine if there was a relationship between the NWI-R and the IPNG total and subscale scores, Pearson correlations revealed a highly significant, moderate, and positive correlation between total IPNG score and total NWI-R score (r = 0.416, P < .001). Additional analyses also found highly significant and small to moderate positive correlations between the NWI-R subscales and the IPNG subscales, summarized in Table 7. The strongest relationships found existed between the NWI-R subscale of organizational support and the IPNG subscale of control over personnel (r = 0.42, P < .001), the NWI-R subscale of autonomy and IPNG subscales of control over practice (r = 0.367, P < .001) and resources supporting practice (r = 0.365, P < .001), and the NWI-R subscale of organizational support and IPNG subscale of control over practice (r = 0.365, P < .001). Smaller but highly significant, positive correlations were also identified between all of the other NWI-R subscales and IPNG subscales, with the exception of the NWI-R subscale of nurse-physician relationships and the IPNG subscales of control over personnel, access to information, resources supporting practice, participation, and goals and conflict resolution. Within these subscales, the only small, significantly positive relationship found was between the NWI-R subscale of nurse-physician relationship and IPNG subscale of control over practice (r = 0.255, P = .014). None of the IPNG total and subscale scores, NWI-R total and subscale scores, and organizational, CNO, and NPC variables revealed a statistical relationship.
This study provides new evidence that nursing SG in Magnet organizations is perceived as primarily management/administration with some staff input. The component characteristics of SG—access to information, influence over resources supporting practice, ability to participate in organizational decisions, control over practice, and ability to set goals and resolve control—are also within the SG range. This study also describes an extremely positive professional NPE in Magnet organizations, with nursing autonomy as the top characteristic, followed by positive nurse-physician relationships, high levels of organizational support, and evidence of nurse control over practice. When examining the relationships between characteristics of SG and NPE, a highly significant and positive relationship between the two was found, providing evidence of the positive relationship between the characteristics of SG and the NPE. This study also identifies highly significant relationships between specific characteristics of SG and characteristics of the NPE. No relationships were found between any of the organizational and demographic variables and characteristics of either SG or the NPE.
Discussion and Implications for Practice
With the average number of years as a Magnet organization at just over 5.5 years, this study describes SG as primarily management/administration with some staff input. It was anticipated that in Magnet organizations, SG models might have been described as more mature, that is, equally shared by staff and management/administration. The fact that it was not described in this way could be attributed to the length of time an organization had SG in place; however, this question was not asked.
Leaders of NPCs in Magnet organizations describe decision authority for 5 IPNG subscale domains to be within the SG range: access to information, participation in nursing affairs, control over practice, resources supporting practice, and influence over goal setting and conflict resolution. Access to information includes information on patient and clinical quality measures, budget and financial information, nursing turnover and satisfaction, and resources to advance nursing practice. Participation in nursing affairs includes participation in unit-based committees on staffing, scheduling, budgeting, clinical practice, and other areas, as well as participation on multidisciplinary professional teams. Control over nursing practice includes shared authority for policies and procedures, nursing standards, performance appraisals, hiring, and continuing education. Resources supporting practice includes determining care delivery models, making patient care assignments, making recommendations regarding new services, clinical positions, and consulting with other clinical care teams. Finally, influence over goal setting and conflict resolution addresses areas such as participating in writing the goals and objectives for the department of nursing, setting unit-based goals, having input into policies and procedures, and addressing conflicts among nurses, between professions, and administration. An organization wishing to implement SG within their organization, or assess current SG structures, may wish to use the IPNG for baseline assessment and compare their scores with the scores of Magnet organizations participating in this study.
Not surprisingly, this study provides evidence of a highly positive NPE in Magnet organizations as perceived by the leaders of their NPCs. The top characteristic, nursing autonomy, includes identifying supervisory staff that is supportive of nurses, access to career advancement opportunities, having decision-making authority for patient care and the work environment, and the ability to execute professional judgment. The next highest characteristic, positive nurse-physician relationships, consists of positive work relationships, teamwork, and collaboration. Next, organizational support includes having time to spend with patients and with colleagues discussing care, having positive work relationships and teamwork with physicians, having control over practice, having enough nursing staff to provide quality care, having a supportive nurse manager, not being in a position where they would need to do things against their judgment, and the opportunity to work in a highly specialized area. Control over practice includes having enough staff to get work done and ensure continuity and quality of care, having time needed to spend with patients and colleagues, and having a supportive nurse manager. An organization wishing to assess the NPE in their organization may wish to use the NWI-R to assess the current state and compare their scores with Magnet organizations participating in this study.
Quantifying the characteristics of SG and the NPE and examining the relationships between the two may assist organizations in making the business case for initiating or sustaining SG structures and/or address areas of the NPE in effort to continually improve nurse engagement and the quality of patient care.
Interestingly, no relationships were found with any of the CNO, nursing practice chair, and organizational variables studied. This may be attributed to the fact that there are multiple influences upon these variables or that the sample size was not large enough to detect significant correlations.
With just less than one-third of all Magnet organizations participating, the generalizability of this study is necessarily limited. Only the NPC chairs were asked to complete the IPNG and NWI-R instruments, an intentional design because there is evidence that managers report higher IPNG scores when compared with staff.1 It would have been interesting for CNO respondents and/or nurse managers to also complete the tools to compare differences between groups and variables. This study focused on the organizational level of SG in the profession of nursing only and did not take into account other nursing organizational councils (eg, education, quality, leadership), unit-based councils, interprofessional council structures, emerging SG structures that span the care continuum, or unit-level nursing councils. Demographic data on type of hospital, for example, community, academic, teaching, nonprofit, or for profit, would have been useful to include and correlate with the level of shared leadership and/or elements of the NPE. Using a number of other nursing empowerment and/or engagement tools could have added additional value to the IPNG-generated data. The current Magnet model and sources of evidence may not align well with the IPNG instrument design. Undertaking a follow-up study would expand the limited number of demographic and organizational variables contained in this study.
Recommendations for Future Research
This study adds to the body of evidence and strengthens the research foundation for structural empowerment in the form of SG and its relationship to the NPE. Future researchers could build upon this study by expanding it to compare CNO, nurse manager, and staff nurse perceptions; explore characteristics of other organizational or interdisciplinary councils and their relationship to patient and quality outcomes; or modify the study design by combining the IPNG with 1 or more nursing engagement and/or empowerment assessment instruments in the field. Further research is needed to not only examine the characteristics of SG but also examine the business case for the allocation of nonproductive time and delve deeper into the value equation. This value equation would include detailed information on the cost/benefit of SG and the identification of cost savings and/or quality improvements attributed to SG. Finally, a researcher may wish to design and test a new instrument that measures elements of structural empowerment in closer alignment with the Magnet model component and sources of evidence in addition to SG that could be used to quantify empirical outcomes.
This study provides new evidence regarding the positive relationship between nursing SG and the NPE in Magnet organizations. Chief nursing officers play a significant role in transforming the nursing work environment through the design, implementation, and evaluation of SG structures. These structures are firmly rooted in the Magnet model component of structural empowerment and support autonomous nursing practice and role development at the point of care. Chief nursing officers are enabling others to act with impact when they enable the profession of nursing to purposefully convene and govern their practice. When nurses are engaged in SG, they are active participants in improving their own nursing professional practice environment.
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