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Department: Evidence-Based Nursing: SHARED GOVERNANCE SPOTLIGHT

Measuring shared governance

One healthcare system's experience

Weaver, Susan H. PhD, RN, CRNI, NEA-BC; Hess, Robert G. PhD, RN, FAAN; Williams, Barbara PhD, RN; Guinta, Lisa MSN, RN-BC, NEA-BC; Paliwal, Mani MBA, MS

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Nursing Management (Springhouse): October 2018 - Volume 49 - Issue 10 - p 11-14
doi: 10.1097/01.NUMA.0000546208.70574.27
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Shared governance is a nursing management model that gives clinical nurses control over their professional practice while extending their influence over the resources that support it.1 Its popularity has skyrocketed as organizations strive to meet the American Nurses Credentialing Center's criteria for structural empowerment to achieve Magnet® recognition or Pathway to Excellence® designation.2,3 But how many nurses participate in real shared governance? If the model is genuine, how many nurses can quantify its strengths and weaknesses? And how many can formulate an appropriate strategic plan for improving the program at hand based on evidence?

Despite the long-time presence and pervasiveness of shared governance (40 years) and professional governance (25 years) in the healthcare industry and literature, hardcore evidence demonstrating their worth has been slow in coming.4 In fact, until governance models of any kind involving healthcare professionals could be quantified, evidence has been anecdotal and its presence only alleged by reputation.5

But there's good news. An extensive assessment instrument is available to answer the above questions without saddling staff with an extensive, but onerous survey. This is how one hospital system used this tool to its advantage.

The tool

In 1994, the 86-item Index of Professional Nursing Governance (IPNG) was created, allowing measurement of professional governance—a concept that encompasses a continuum of traditional, shared, and self-governance. With rigorous methodology, the IPNG provides empirical evidence of not only the extent of shared governance implementation, but also its connection to professional, organizational, and patient outcomes. In fact, the IPNG has provided evidence that shared governance is associated with professional outcomes, such as nurse satisfaction and empowerment, and organizational outcomes, such as a professional practice environment.6-8 In addition, nurse researchers are now connecting shared governance with patient outcomes, such as fall rates, fall with injury rates, pressure injury incidence, medication management, and patient identification errors.9,10

A recent assessment of the psychometric properties of the IPNG 2.0 found that the instrument takes 20 minutes to complete.11 Over the years, some researchers have reported that nurse respondents didn't complete the survey, leaving some subscales completely blank, and requested that the length of the IPNG be shortened. In 2017, the author of the tool used factor analysis to reduce the items to a 50-item IPNG 3.0 version while maintaining its validity and reliability.

The IPNG 2.0 and the shorter IPNG 3.0 measure nursing governance along a spectrum from traditional (administration/management primarily makes decisions), to shared (shared decision-making), to self-governance (staff members primarily make decisions). The IPNG has six subscales representing the dimensions of professional governance. (See Table 1.) Participants respond using a 5-point Likert scale, ranging from “nursing management/administration only” (1), to “equally shared by clinical nurses and nursing management/administration” (3), to “clinical nurses only” (5).

Table 1:
Table 1::
IPNG and IPNG 3.0 subscales

Our experience

In 2013 and 2015, assessment of nursing shared governance was conducted at Hackensack Meridian Health's five southern hospitals—Bayshore Community Hospital, Jersey Shore University Medical Center, Ocean Medical Center, Riverview Medical Center, and Southern Ocean Medical Center—by surveying nurses utilizing the original 86-item IPNG survey. The majority of respondents in 2013 and 2015 had a baccalaureate degree and were clinical nurses. (See Table 2.) Yet, despite having shared governance in place for many years, the nurses perceived overall governance to be in the traditional range in both 2013 and 2015. (See Table 3.)

Table 2:
Table 2::
Demographics
Table 3:
Table 3::
IPNG 2.0 results, 2013 and 2015

After the 2015 survey, steps were taken to explore why the nurses perceived a traditional governance structure. A survey was sent to nurses throughout the hospital system about the strengths, weaknesses, opportunities, and threats to the current shared governance model. The nurse respondents identified five action items: 1) provide education on shared governance, 2) improve communication, 3) improve unit-based council (UBC) meetings, 4) involve night-shift nurses, and 5) increase nurses' participation.

A task force of clinical nurses, nurse educators, nurse managers, and senior leaders from the five hospitals was formed to address the survey action items and discuss how to move toward a shared decision-making model. The first step was holding education programs on shared governance for all nurses. Then, since the voice of the nurse is the cornerstone of nursing shared governance, communication was enhanced by providing all nurses with hospital email so there was an additional way to communicate vital information across the system. Next, the UBC meetings were redesigned. The traditional monthly staff meetings were merged with the UBC meetings with a shared agenda, led by the UBC chairperson and facilitated by the manager. Because clinical nurses across the system are required to attend at least 50% of the unit meetings, this initiative heightened participation. Night-shift councils were also developed at every hospital because clinical nurses working the night shift wanted to be involved in shared governance and have a forum to address issues that are unique to them.12

Last, and most important, a Nursing System Council Day was initiated to better engage clinical staff in meaningful problem-solving. Each hospital's chief nursing executive recruited six clinical nurses, a nurse manager, and a nurse educator to attend the Nursing System Council Day to have frontline nurse participation in decision-making. New councils emerged to add or replace the existing system councils, including the ambulatory council, informatics council, professional growth and development council, quality and safety council, new knowledge and innovation council, and transitions of care council. These councils meet simultaneously on the morning of Nursing System Council Day, followed by an education program. The Nursing System Council Day concludes with the coordinating council, which was formed so that clinical nurses and leaders from all councils can review and discuss ideas, suggestions, and issues brought up from nurses throughout the system.

After the new shared decision-making structure was in place for 18 months, an assessment of nursing shared governance was conducted with nurses at six hospitals, including Raritan Bay Medical Center, to determine the extent to which they perceived that shared governance had been implemented throughout the system. The 50-item IPNG 3.0 was used and system-wide scores, as well as campus-specific scores, were calculated.

The results from this survey indicated that, overall, nurses throughout the six hospitals perceived that nursing governance was within the shared governance range; that is, governance was shared between staff and administration/management. (See Table 4.) More specifically, clinical nurses perceived that they have access to information, influence over resources supporting their practice, control over their practice, and the ability to set goals and resolve conflicts. Furthermore, results from individual campuses indicated that nurses at five of the six hospitals perceived governance to be in the shared governance range.

Table 4:
Table 4::
IPNG 3.0 results, 2017

After implementation of the new shared decision-making structure, governance at these hospitals changed from traditional to shared governance. The researchers shared this results at the system-wide Nursing Congress and at each of the hospitals, and discussions ensued regarding strategies for improvement. The new shared decision-making structure will continue to evolve and be nurtured until the next survey in 2019.

Discussion

Although many hospitals and healthcare systems have shared governance in place, this doesn't necessarily ensure that the underlying principles of shared governance are embraced, as was evident in our experience. To determine if clinical nurses perceive they're truly involved in making decisions that affect nursing practice, it's important to use a tool with established validity and reliability such as the IPNG. Further, the subscales that compose this tool allow organizations to assess areas in which shared governance has been implemented, as well as areas needing improvement. We speculate that the use of the shortened version of the IPNG was one factor in increasing survey participation.

Conducting a shared governance survey has its challenges. Organizations can benefit by careful planning and implementing strategies to facilitate a successful survey. In our organization, a nurse subinvestigator was available at each of the hospitals to promote awareness of the survey, answer questions, and troubleshoot unanticipated issues. Additionally, when planning this survey, our research team was concerned about survey overload due to competing surveys in which nurses were expected to participate, such as the National Database of Nursing Quality Indicators® and employee satisfaction polls. To avoid survey overload and confusion, we conducted our survey at a time when there were no other nursing surveys. And although nurses may have very good intentions to complete the survey, doing so may slip their minds as more pressing concerns arise. To provide reminders, we distributed small packets of M&M's candies on every unit with the attached note, “ReM&Mber the shared governance survey.” Lastly, when the results are obtained, organizations can benefit by acknowledging the areas that need improvement. Then it's essential to invest the time and energy into identifying changes that need to be made and how those changes will be implemented. It's critical during this process to include input from clinical nurses.

Time well spent

Measuring shared governance is a time-consuming activity that requires coordination across the system, but it can be a valuable and rewarding one. Appropriately scheduled surveys should be conducted, along with nurturing shared governance with educational programs. Nurses wonder about how often surveys measuring shared governance should be administered. The answer is simple. You should survey when you think a change has occurred. After we used IPNG-derived surveys to enhance our governance model, we felt that a change had occurred. And it had—the evidence indicated that we finally achieved system-wide nursing shared governance.

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