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Principles for sustaining shared/professional governance in nursing

Porter-O'Grady, Tim, DM, EdD, APRN, FAAN, FACCWS

doi: 10.1097/01.NUMA.0000550448.17375.28

Learn about the three fundamental principles that both affirm and validate the presence of effective and sustainable nursing professional governance structures and practices.

Tim Porter-O'Grady is a senior partner, health systems, at TPOG Associates, LLC, and a clinical professor, dean's advisory board, at the Emory University School of Nursing in Atlanta, Ga.

The author has disclosed no financial relationships related to this article.



Now more accurately identified as professional governance, shared governance focuses on the creation of a structural framework for nursing practice consistent with the frameworks that govern other major professions.1 Many of the challenges associated with governance in the nursing profession have been strongly determined by long and well-established “employee workgroup” management structures and practices developed within a hierarchical framework common to the majority of corporate workplaces.2 Although there's been much emphasis and effort devoted to dialogue and expectations of professional orientation, accountability, behaviors, and practices, many of the structural requirements to support such processes run directly counter to employee workgroup requisites, policies, management structure/practices, and hierarchical role expectations. This fundamental contradiction between the requirements of professional practice and the requisites of traditional hierarchical management structure/practices with resultant employee workgroup behaviors created the conundrum that's driven the 35-year journey to construct and implement a sustainable structure for truly professional nursing practice.3 (See Table 1.)

Table 1

Table 1

Professional governance isn't a management strategy, model, tactic, approach, or operational component. Rather, 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. On the one hand, professions are generally considered to fulfill a defined social requirement/behavior that acts for the good of society at large. Indeed, professions are set apart and regulated in a way that ensures the advantage and advancement of the public interest in a manner that's generative, safe, and, in the case of nursing, has a net aggregate positive impact on the health and well-being of the population. Professions are required to govern themselves in the best interests of those they serve, evidenced in standards of knowledge generation and implementation, education, practice, indicators of quality/impact, competency requirements, ethics, disciplinary processes, professional behaviors, and the requisites of licensure.

In the past 35 years, thousands of healthcare organizations and agencies have implemented shared/professional governance models within their nursing organizations to create appropriate structures for governing the profession.4 Each has taken into consideration its organizational parameters, administrative processes and tolerances, leadership capacity, and levels of staff engagement in influencing professional governance design and approach. In the beginning, much of the activity around shared governance reflected on novice understanding of the characteristics and implications of model design and governance structure choices. Some organizations reflected scholarly rigor that demonstrated their commitment to precedent and principle. However, most experimented with approaches they believed would more fully empower and engage nursing staff in decisions and actions with a direct impact on their practice.

A host of publications over the succeeding years have provided a guide for a more systematic approach to constructing, operating, and managing within professional nursing governance structures. Throughout this considerable time, foundational principles have emerged that best describe the essential constructs of professional governance as it applies to nursing. These principles serve as a template of the elements necessary for constructing sustainable professional nursing governance models regardless of the setting.

Although a range of principles exemplify the characteristics of a functioning professional governance model, 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; 2. Structures are built around professional accountability and clinical decision-making; and 3. Professional governance structures reflect distributive decision-making. These three principles are shared here to clarify the key elements of nursing professional governance and the characteristics essential to its sustainability.

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Principle 1: Professional governance is grounded in practicing nurse accountability

The whole point of professional governance is lost if it isn't grounded in the professional's obligation to demonstrate personal accountability for ownership of the work. This notion implies an individual obligation that demonstrates a personal connection to and ownership of the principles and practices associated with the profession. Nursing is a practice profession. Its focus ultimately leads to having a positive impact/outcome on the people it serves. This impact/outcome is achieved through the actions of nurses who reflect through their own behavior, the principles, standards, protocols, and practices legitimized by the professional body. The assumption here is that the members of the nursing profession, through their individual accountability and collective relationship and activity, establish common foundations for practice they determine in concert are essential to their work. This intersection between the individual member's and collective members' accountabilities defines the fundamental and functional characteristic of all professions. This is further represented by the assurance that the decisions in a profession will reflect the appropriate “locus of control.” (See Table 2.)

Table 2

Table 2

The expectation is that the profession as a whole has a right and obligation to define its work, set its standards, establish its collective obligation, and expect workers' actions to be consistent with its standards. This is the compact between each member of the profession and the profession as a body. It's out of this obligation that nurses have the right to exercise their accountability for ethics, principles, standards, requisites, and practices represented in codified professional standards (such as The Code of Ethics for Nurses) and legislated social regulations (such as state boards of nursing regulations). The foundation for this “social mandate” is society's expectation that the profession will act in the people's best interest at the highest levels of knowledge, ethics, and practices in a way that society will honor and protect.5

The exercise of ownership and accountability for professional standards and practices belongs to the members of the profession. In fact, in every state in the US, it's illegal for those outside of the licensed professions, including nursing, to define and control the profession's work. This is a centerpiece of professional nursing governance and the driving core upon which all governance structures are built. At the center of professional governance models are the practicing nurses who have primary accountability for decisions and actions that influence and impact clinical nursing practice. (See Table 3.) Therefore, in most professional nursing governance organizations, a nursing practice council has the collective obligation/accountability for practice decisions.6

Table 3

Table 3

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Principle 2: Structures are built around professional accountability and clinical decision-making

Most traditional organizations are built around locus-of-control authority structures. These “line-and-box” relationships are designed to establish an infrastructure for effective decision-making and organizational work. In these models, workers are 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.

On the other hand, professions operate out of an entirely different set of structures and relationships. Rather than traditional responsibility of employees to their organization and its management, professions are fully accountable to the populations they serve. This unique locus of control between professional and person distinguishes the work of the professions from other kinds of work. In this case, professionals own their decisions and actions, and are personally accountable for the impact those actions have on those they serve. Therefore, it's the obligation of the institution and its management to provide an infrastructure that both supports and advances the profession's work and each professional accountable for its appropriate exercise.

For nursing professionals, this means the organizational structure is obligated to ensure that they can fully and freely practice within defined professional standards and obtain/sustain positive outcomes as products of this work. In short, the organization has a structural accountability (systems and supports) that doesn't impede the content accountability (standards and practices) of the profession and the practicing nurse. This represents a partnership between the profession and the organization rather than a dependency or subordinate relationship of the profession to the organization and its management. Although this hasn't necessarily been reflected in the historic employee relationship of nurses to organizations, it does reflect the predominant characteristic of a mature profession's relationship with the organization as each fulfills its role in advancing and supporting the work of nursing.

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Principle 3: Professional governance structures reflect distributive decision-making

Professional structures are organized around decisions, not positions, reflecting the distribution of accountability for those authorities that are unique to the profession. All professions have accountability for practice, quality, competence, and knowledge. Every profession has ownership of and a practice obligation to these four fundamental accountabilities. In fact, the ownership of these accountabilities provides “reserved authority,” which obligates the profession to define, apply, and evaluate the products of practice associated with them.

In professional nursing organizations, this means that nurses are specifically accountable for the ownership of practice, quality, competence, and knowledge. Because these are exclusively professional accountabilities, structures and mechanisms for their ownership must be part of the contextual framework that supports nurses' obligation to fully exercise the accountabilities in an appropriate and productive way. Historically, nurses were managed in such a way that the obligation for these accountabilities was traditionally subsumed as part of the nurse manager role. In healthcare, the only exception to this rule was the medical profession in which the infrastructure more closely aligned with the fundamental accountabilities. The “noise” experienced in the past 35 years as these same principles are applied to nurses has been derived from the conflict between the traditional structure of the nursing workplace and the requisites of the four professional nursing accountabilities.

The structures of shared/professional nursing governance have attempted to resolve this conflict in a way that creates an organized and systematic approach to governing and leading nursing practice. Implementation of professional governance has proceeded in a manner that more positively advances nursing practice and raises the potential for nurses to more fully improve the health of individuals and communities. Constructing a shared/professional governance infrastructure within the context of an accountability framework for nursing practice encourages the commitment and practice of nurses in a way that reflects both the obligations of ownership and the positive outcomes of its application to their actions.

These shared/professional governance structures provide the scaffolding that's essential to frame the accountabilities of practice, quality, competence, and knowledge. However, the structures only work if they can actually transform professional nursing practice. Although contemporary systems science clearly demonstrates the contextual framework that structure directly creates for aligning human behavior, the changes in that behavior still depend on concerted and compatible action on the part of nurses and their leaders.

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On our way

Professional nursing behaviors require significant universal application of sustaining governance structures in every clinical organization where nurses practice. Half measures, management-driven control structures, ego-driven or self-centered leadership strategies, top-down hierarchical organizational models, and controlling leadership and management practices aren't consistent with shared/professional governance principles and practices. Indeed, they're the predominant barrier to them. In my own experience over the past 35 years, I've seen many organizations suggest that they're implementing shared/professional governance structures but, because of these constraints, they're at best only half measures that ultimately end up being modifications to and accommodations of a fundamentally unchanged traditional hierarchical management structure.

Still, the journey to full professional equity, ownership, and accountability for the nursing profession is clearly well on its way. Although much work has been done and change is evident, a good volume of that work still needs to unfold. As Millennials—born in an age of expectations for equity, advancement, and fulfillment—join the nursing profession, the demand for fuller ownership, engagement, empowerment, and impact will accelerate. And as more nurses educated and grounded in the concepts that underpin professional equity and governance become leaders, the more these expectations will be advanced.

The work of nursing leadership will continue to “push the walls” of historic patterns of behavior that are no longer relevant, creating even more viable and appropriate structural and practice models suitable for supporting professional nursing practice and advancing the partnership necessary for truly sustainable and value-based healthcare. It's only when the alignment of these principles, the forces of change, and the accountable and equitable behaviors between the disciplines occur that the full potential for transforming the health of the nation can be fully realized.

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