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The evolution of nursing shared governance at a community hospital

Painter, Kathleen BS, RN, CAPA; Reid, Stephanie MBA, BSN, RN; Fuss, Elizabeth P. MS, RN, CIC

doi: 10.1097/01.NUMA.0000432228.68831.13
Department: Team Concepts

At Carroll Hospital Center in Westminster, Md., Kathleen Painter is the executive director of surgical services, Stephanie Reid is the CNO and vice president of quality, and Elizabeth P. Fuss is an infection preventionist and associate health manager.

The authors have disclosed that they have no financial relationships related to this article.

In today's fast-paced, ever-changing healthcare setting, nursing is being challenged every day to provide quality care to patients based on evidence-based practice (EBP) with a patient-centered focus, while ensuring that patient satisfaction is always achieved. At our 180-bed hospital, which employs 600 nurses, we realized that best practices were positively impacting patient care, but often on only one or two of our nursing units. Our community hospital chose to empower nurses and improve patient care throughout the hospital by implementing a best practice shared governance framework within our nursing division.1

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How it began

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Initially, a nursing shared governance steering committee was formed, comprising the CNO, nursing leaders, and direct care nurses, with 15 team members in total. We formulated a plan and objectives to define our nursing shared governance for best practice and drafted guidelines. Our next steps included meeting with the nursing teams on all nursing units to share our goals and purpose.

Our objectives were for nursing best practice councils to define and provide a mechanism for nursing to establish, uphold, and communicate practices and standards within our hospital while empowering nursing staff to practice with a higher level of autonomy. The best practice committees on each unit and the coordinating council would strive to create an organizational environment in which individual professional accountability is encouraged and expected. This process provides organizational support for direct care nurses and encourages commitment to quality nursing practice and outcomes through shared governance. Another objective of the best practice committees was to focus on Hospital Consumer Assessment of Healthcare Providers and Systems scores by promoting initiatives to improve our ranking, with the goal of becoming part of the top quarter in the nation and number one in the region for quality outcomes.

Under new leadership in 2007, OR staff members were struggling to uphold three committees: safety, policy, and education. Many topics were shifted from one committee to another without significant progress or outcomes, and the committees lacked regular attendance and participation. After the best practice model was drafted, all three committees were combined, with the OR clinical manager initially chairing the new committee. The initial plan required a staff member to take over as chairperson after 1 year. The position would then be rotated each year, with the chairperson elected by the committee members.

After introducing the idea of the best practice committee to the staff, an abundant number of staff members wanted to participate. The design called for no more than 12 members, some rotating off each year to allow others to participate. OR scheduling was modified to allow late starts on 1 day of each week to provide meeting times. The OR best practice team was very successful in creating an atmosphere of empowering staff members to make changes when they saw safety issues, inefficiencies, or the need to update policies and procedures in accordance with Association of periOperative Registered Nurses standards or EBP. (See Table 1.)

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Further evolution

The OR best practice committee was a success story. The sense of accomplishment within the OR led to many positive changes that wouldn't have been possible using an authoritative approach. Team members realized that they had the power to change their work environment through collaboration and teamwork. The directors and managers became their support and offered guidance, but they were governing themselves and improving practices.

Following the success of the OR, the CNO instructed each nursing unit manager to formulate a unit-based best practice committee. Monthly meetings of the best practice council allowed for the sharing of ideas implemented on one unit. Over time, other units started to implement best practices that were started on different units and, eventually, best practices created hospital-wide changes that improved patient care, outcomes, and satisfaction. (See Table 2.)

Our model has been in existence for 5 years and is thriving. A best practice steering committee, comprising key nursing directors and clinical managers, continues to meet quarterly to discuss the progression of our shared governance model and how we can continue to challenge our nursing staff through the best practice model. Challenges exist on smaller units and some units struggle to find suitable times for meetings with representation from all shifts. Telecommunication has helped achieve wider representation. All nursing units now have best practice committees chaired by staff members, not clinical managers. (See Figure 1.)

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Professional development

Although the best practice model was established to promote professional development, after 5 years of shared governance, we defined some weakness in its professional development arm. A small subcommittee was formed to make changes to our clinical ladder requirements and continuing education for nurses. All nurses are now required to obtain 10 contact hours each year, although our state doesn't require contact hours for license renewal.

Our RN clinical ladder model has four levels. Clinical nurse IV now requires a bachelor's of science in nursing (BSN) degree, and clinical nurse III now requires a certification in the nurse's specialty. Many of our entry-level nurses are associate of arts prepared, but we knew the nursing practice of the future will require more advanced degrees. Current clinical ladder staff members have 3 years to complete their degrees or certifications to remain on the ladder. New applicants must have their BSN or certification upon hire.

In addition, to continue to develop our frontline leadership, we're planning a workshop for patient care coordinators to offer them guidance and further their skills in the daily management of patient care units.

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Direct line to change

The shared governance culture can't be accomplished without visionary leaders who support nursing empowerment through shared decision making, encouragement of self-motivation, positive leadership, and clinical development. Shared governance supports direct care nurses' authority, responsibility, and accountability for patient care and processes that sustain quality patient care. Our nurses have a direct line to move ideas into reality and become change agents who improve quality of care, patient outcomes, and patient satisfaction.2

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1. New N. Shared governance: Virginia's empowering nursing leaders speak. Nurse Leader. 2009;7(5):44.
2. Moore SC, Wells NJ. Staff nurses lead the way for improvement to shared governance structure. J Nurs Adm. 2010;40(11):477–482.
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