Shared governance has been in place within nursing services at Regional Health Rapid City Hospital in South Dakota since 2008. Like most organizations, it took us time to implement the new structure and learn to lead and function in a shared governance environment. After months of hospital-wide council development, election of council leadership, and education for facilitators and council members, we had an active and thriving shared governance structure. The hospital-wide councils grew and evolved over the next several years, and unit-level councils were developed and experienced various stages of success. Attendance at the hospital-wide councils was consistent and members were engaged in establishing annual goals that helped move organizational priorities forward.
We continued in this direction until some of the hospital-wide and unit-level councils began to experience decreased attendance and engagement in 2017. In addition, our healthcare system had expanded to include 5 acute care hospitals, over 21 ambulatory clinics, and 2 long-term-care facilities. We needed to broaden the scope of the hospital-wide councils to system-level councils and formally include interdisciplinary members (many had been added as ad hoc to councils at that point). The council chairs and nursing leaders agreed that we needed to embark on a large-scale shared governance redesign.
This article describes the redesign process, including Regional Health's efforts to utilize the concept of appreciative inquiry (AI) to keep the best of what we had, focus on our strengths, dream of “what could be,” and deliver a compelling change.
Regional Health formed a 16-member redesign team in March 2018 to oversee the redesign process, consisting of six clinical nurses, four nurse leaders, two interdisciplinary members (a pharmacist and a medical imaging staff member), one quality department nurse, one nurse educator, one patient experience specialist, and one clinical informatics director. However, many qualities of our current structure were working and the council chairs expressed that they didn't want to lose any of our strengths. In reviewing the literature, we found an article in American Nurse Today titled “Sustaining Shared Decision Making: A Biennial Task Force Process.”1 The authors described how their shared decision-making task force incorporated the AI model to guide its work. This sounded exactly like what we needed to maintain and capitalize on our strengths, focus on positives, and guide us forward to dream big in our redesign.
AI seeks to engage stakeholders in change processes through methods of inquiry to help generate new ideas and imagine what could be. Then, a desired and compelling future state is collectively designed.2,3 AI also involves a 5D cycle—define, discover, dream, design, deliver—as a practical approach to address change at an individual, team, or organizational level.4 (See Table 1.)
Our first redesign meeting in May 2018 set the tone for a positive and innovative day with a team-building exercise that encouraged creativity and fun. We had quotes around the room that spoke to positivity, passion, and focusing on strengths. Our area of work had been defined for us: to create a shared governance structure that included our entire system and incorporated interdisciplinary membership.
After reviewing the assigned prereading and ensuring that all members understood the principles of shared governance, we introduced AI to the redesign team. Members of the redesign team who had been intimately involved in the previous shared governance structure liked the idea of focusing on the positives and keeping what was working well.
Several methods were utilized to discover our current state. Online surveys were distributed to council members and nursing leaders throughout the system, with 57 responses (just under 50%). We also asked members at council meetings what was working well that they didn't want to lose in a new structure. Members of the redesign team responded to the Index for Professional Nursing Governance (INPG), which examines who has control, influence, authority, participation, ability, and access using a 5-point scale assessing topics in which shared decision-making could be utilized.5 Results from these data-gathering methods were shared at our first meeting.
The INPG results showed significant variation among responses for the areas of control and participation, but most ability and access were “equally shared by clinical nurses and nursing management/administration.” The area of influence indicated that with staffing decisions, daily assignments, patient flow, supplies, and enlisting support, most responses were “primarily clinical nurses with some nursing management/administration input” or “clinical nurses only.” When it came to influence over budgets, salaries, and creating new positions, most respondents chose “nursing management/administration only” or “primarily nursing management/administration with some clinical nurse input.”
Overall, the INPG and online survey results demonstrated that our current structure was collaborative. The departments and individuals participating in shared governance were highly engaged and perceived that they were able to participate and influence change in the work environment. In addition, the work of the current councils generally supported the organization's mission, vision, and goals.
The redesign team members then broke into two smaller groups and brainstormed further on the existing system's strengths and what was working well. If problems were identified, the facilitators encouraged the groups to see them as opportunities and then refocus on “best of” components in our existing structure.
“Dreaming” was one of the most enjoyable parts of the process. All members of the redesign team were given sticky notes to write down what they wanted to see in a new structure. No ideas were too grand or off limits. The facilitators asked questions such as “What would shared governance look like if it were functioning at its best?” or “What membership behaviors would make us great?” Sticky note ideas were placed on the walls and grouped into themes. The themes were then shared and expanded upon by the team until seven general “dream” themes emerged. (See Table 2.)
Some of our dreams were big with specific expectations and as we moved into the design phase, they were placed in a “next steps” category. Some were smaller and achievable in the short term, such as an electronic platform for council communication. We also chose to name our new structure the “Regional Health Nursing Shared Decision-Making Structure” because it more clearly explained the purpose.
At our second meeting, we began to design how we would bridge the gap between “what is” and our dream. We reviewed different types of shared governance structures in the literature and their pros and cons.5 We drew our dream state and compared our picture with the different types of structures. Ultimately, the councilor structure with strong components from the practice or unit-level model were chosen as the building blocks for the new structure. Because we wanted the unit councils to be the foundation, or core, of our new structure, their purpose was defined first. The rest of the systemwide councils were identified based on our strategic priorities and by frequently referring back to “the dream.”
Templates for council charters were developed in which specific components, such as its purpose, were defined by the redesign team and other components, such as annual goals and meeting times, were to be defined by the new council members. Some items, such as minutes templates, council leadership education, and better communication tools, were identified as needing to be developed but not required before we began to socialize the new structure and gather feedback.
In August, September, and October 2018, we began previewing the new shared decision-making structure to our existing hospital-wide councils, nursing leadership, and system leaders. We asked for feedback, input, and questions about the new structure. Any suggestions or questions were reviewed in our next redesign team meeting, and the team clarified some of the council's purpose statements to strive toward reaching the vision that was developed during the “dream state” portion of the AI process. The team also broadened some memberships to be more inclusive and refined the nomination process and length of terms.
The team established a timeline for the council rollout starting with the unit/market/clinic (UMC) councils (named to encompass our inpatient, outpatient, and critical access hospitals) and listing the order in which systemwide councils would begin. It also developed smaller workgroups to begin the education for the rollout, including council leadership education, and work on tools to improve communication. We now have 18 UMC councils completed or in progress, and enthusiasm for the new structure is still high. (See Figure 1.) Resources from the redesign and Magnet® steering teams have been assigned to assist areas that are establishing a UMC for the first time. UMC charters are being submitted to the coordinating council for review and any areas without a charter will be contacted to evaluate their progress or need for further assistance.
The first systemwide council, a healthcare informatics council, began in April 2019, with other systemwide councils scheduled to launch every 2 to 3 months. (See Figure 2.) The redesign team transitioned its work to the coordinating council to continue the rollout, develop communication tools, and guide the system councils and UMCs. Council member and leadership education is being developed, and ideas to improve communication are being gathered organically as the UMCs are forming and submitting ideas to the facilitators and coordinating council.
An electronic interactive learning module that takes approximately 30 minutes to complete has been developed for council leadership and members. Topics include member expectations, communication to and from the councils, the consensus decision-making process, understanding council leadership roles, and creating SMART goals. Nineteen videos can be viewed as needed and take approximately 2 minutes each. Council leaders also receive education on evidence-based practice and how to utilize data, create an agenda, run an effective meeting, and take meaningful meeting minutes. Educational offerings are also being developed for clinical nurses explaining the purpose of shared decision-making and how to get involved and bring ideas forward.
The journey to redesigning our shared decision-making structure has taken 18 months and the time and engagement of multiple clinical nurses, previous council leaders, and nursing leaders. The AI process allowed us to harvest what was working well in our current structure, identify opportunities for improvement, create a vision for the future, and facilitate systemwide change to deliver the vision. During the process, we had new nurses join the team and new nursing leaders assume the facilitator roles to continue guiding the process forward. Since the original redesign team developed the structure, we've had interest from patient care champions (nurse's aides) and advanced practice providers and have included them in the shared decision-making structure.
Challenges we've encountered include robust engagement from nursing areas that weren't previously involved in shared decision-making; clinical nurses who were part of the previous structure and redesign wanting to continue on systemwide councils, which could potentially limit the number of new nurses involved; and a transition of nursing leadership during the delivery portion of the process that's lengthened our timeline. Moving forward, we plan to evaluate the health of our shared decision-making structure at least every 2 to 3 years to ensure that we're meeting our goals and engagement remains high.