Gillette Children's is a pediatric subspecialty healthcare organization in St. Paul, Minn., providing care for patients with brain, bone, and movement conditions needing specialized expertise. The unique patient population allows our nurses to be innovative in the care provided for children who have rare or complex medical conditions. Our organization has a 60-bed hospital and 11 clinic sites in Minnesota, with nearly 400 nurses working in all areas of the organization. Orthopedics, neurology, and neurosurgery are the largest of the 28 clinic programs Gillette offers.
Gillette's nursing clinical shared governance (CSG) commenced in 2007. Over the years, the model had been revised, with modifications that affected structure (such as changes to unit-based council and committee composition and focus), but participation and organizational impact remained consistently modest.
In 2019, in response to diminished engagement and absence of appreciable outcomes, an evaluation of nurses' satisfaction with CSG was completed by conducting a World Café at one of the biannual CSG Gatherings.1 Findings from that evaluation confirmed nurses were dissatisfied with the shared governance model. Specifically, nurses identified four major pain points: 1) duplication of work and silos; 2) diminishing engagement; 3) perceived lack of authority to make decisions; and 4) lack of clarity about how the work executed in CSG aligned to organizational priorities.
Revising the model
In response to the World Café session, a CSG task force formed under the direction of the CNO to revise the model. Task force members included nurse educators, nursing specialists (clinical practice, research, quality and safety, and education), nurse managers, assistant vice president of hospital operations, and staff nurses. The task force was chaired by the clinical practice nurse specialist, met weekly, and designated subgroups to complete assigned tasks.
The task force paired the World Café meeting takeaways with published evidence on professional governance best practices to construct a revised model. A high priority was to transition from participatory to shared decision-making to promote nurses' control over their practice, resulting in improved quality of care delivered.2 Our new structure's values are informed by best practices on shared decision-making and leadership styles needed to support a successful model.3 The revision team also evaluated professional governance structures at healthcare organizations in the US to inform the revised model, consistently finding models that promote shared decision-making and interdisciplinary communication.4-9
The result of the revision effort is a multidisciplinary model (see Figure 1), where we've invited non-nurse clinicians to participate alongside their nursing colleagues. This strategy was operationalized in two phases. Phase one in early 2020 involved inviting nurses to pilot the new clinical shared governance structures. The CSG task force created a collaboration between Gillette's Performance Management Strategy Office (process improvement experts) and our nurse specialists to educate CSG members on evidence-based practice (EBP) and process improvement methodologies. In fall 2020, non-nursing clinicians were invited to join the Governance Re-Visioning Task Force with an aim for 2021 integration of these disciplines into CSG. That stage led to phase two of our implementation strategy, which included the following: representing all clinical care disciplines in CSG with the introduction of new, non-nursing clinical care councils beginning in May 2021; establishing plans for ongoing evaluation of satisfaction and productivity; and emphasizing the organization's core values when executing priorities.
The foundation for the newly revised structure was a dedication to providing a structural model for clinicians, including but not limited to nurses, with emphasis on professional autonomy via control and decision-making power over their practice. This focus reflects published guidance on professional governance structures.10 It differs from traditional nursing professional governance structures that might include non-nurse clinicians as contributors but not members.
Evolution from old to new
There are distinct differences in both structure and focus between our old and revised CSG model. The original model had department-level councils and several focused committees, the latter led by a staff chair and supported by a nurse specialist. A barrier with this structure was that the committees lacked connection and a standard communication strategy with the department councils, and they had no relation to organization-level initiatives. This resulted in siloed efforts with minimal visibility to the broader department of nursing or the organization. Additionally, upon critical review, there was notable duplication of work, with nurses addressing practice and process issues unaware that non-nursing departments were tackling similar problems.
The revised model has department- and discipline-specific councils called CSG Teams. This ensures nurses and their colleagues maintain the ability to ask and answer questions specific to their practice. Despite the small size of our inpatient hospital units, our nursing CSG teams are assigned by nursing specialty (such as neuroscience, orthopedics, rehabilitation, and intensive care) because their practice experiences are appreciably unique. Wanting to promote that same opportunity for our newly added disciplines, the CSG revision task force established eight new CSG teams. These new CSG teams include the following disciplines: care management; patient access; rehabilitation therapy; child and family services; respiratory therapy; imaging; pharmacy; and orthotics, prosthetics, seating, and casting (OPSC).
Feasibility dictated the composition of some groupings. For example, all therapists (speech, occupational, physical) form one team, and our child and family services department has one team. The latter includes numerous specialties (such as social work, interpreter services, and child life specialists), but they share a general reporting structure and felt they could be most effective as one team. Respiratory therapy, imaging, pharmacy, and OPSC are separate teams based on their specialty discipline. This allows all disciplines to generate clinical inquiry in their area of practice while encouraging interdisciplinary collaboration.
Our current model (see Figure 1) conceptualizes an empowerment structure with clinicians, patients and families at the center. Layers of support surround the central CSG teams, with the first supportive layer being the Pillar, where experts in areas of research, education, technology and innovation, and clinical practice meet with CSG team representatives monthly to escalate initiatives, remove barriers, and provide opportunities for sharing ideas and making decisions. The outer layers of the model are the Coordinating and Quality and Safety councils, both operationalizing leadership support.
CSG teams meet monthly to find solutions in the areas of clinical practice/care delivery, performance improvement, professional development, patient experience, and engagement/healthy work environment. It's typical for CSG team-level initiatives to be piloted, then shared at the Pillar for broader implementation, a strategy that reduces duplication of efforts among teams. At all levels in the structure, decisions are made by consensus with emphasis on shared decision-making.
The Pillar-level committee consists of interdisciplinary members from all CSG teams. The purpose of this committee is to evaluate projects for potential for broad application, promote collaboration, and act as a CSG communication hub. Currently the CSG Pillars are operationalized as one committee, meeting monthly, resulting in strengthened support for CSG teamwork.
The next layer of our structure, the Coordinating Council, connects CSG and organization leaders with a focus on CSG sustainability and alignment with the organization's strategic goals. The Coordinating Council meets every other month, and CSG leaders are responsible for providing quarterly reports to the Quality and Safety Council.
A professional governance structure will be ineffective without support mechanisms in place to promote strength and sustainability. We continually look at our processes with a critical eye to identify areas for improvement. One area that has been particularly challenging is accurate tracking of CSG work. We currently use an initiative tracking document as a dashboard for all CSG teams and have trialed a time tracking tool, but inconsistency among teams maintaining accurate data limits the ability of these tools to reflect impactful outcomes. As a next step, we're partnering with our Information Services department to develop an interactive platform aiming to capture productivity and outcomes to clearly articulate CSG value with minimal burden on clinicians to complete forms.
We're committed to finding successful approaches to measure CSG work and experiences, allowing us to highlight the value of an empowerment structure. In recent years, we've used original surveys and listening sessions to evaluate the effectiveness of our model. Surveys aimed to explore perceived success and failure related to engagement, partnerships, processes, project progression, and barriers. These data have been helpful for goal setting and education planning. Moving forward, we're exploring validated instruments to measure behaviors associated with advancing professional governance, including the Structural Professional Governance Self-Assessment Survey and the Verran Professional Governance Scale instruments.11,12 There are limitations with these instruments because they've only been validated in populations of nurses, but because nurses comprise a large percentage of our staff, we think we can glean useful data to inform sustainability for all clinicians.
In addition to our commitment to critically assess our professional governance state with validated instruments, we've added a CSG program manager role to promote sustainability of our revised structure. The CSG program manager is a nurse, responsible for the day-to-day operations of CSG who supports EBP and quality improvement initiatives. In spring 2022, we consulted with a national expert on nursing professional governance who served as the keynote speaker at our 2022 CSG Gathering and consulted with smaller groups for more focused direction and support. Nurse managers, the CSG Team chairs, and all non-nursing members of CSG were selected for the extra time with a professional governance expert to ensure they had a foundational understanding of the purpose of professional governance and their role and responsibilities within our structure to promote shared decision-making.
Benefits of the revision
Our evolution from a nursing shared governance structure to an interdisciplinary professional governance structure continues to evolve with lessons learned. A key strength of our model is the system-level support for interdisciplinary collaboration, promoting successful execution of organization-level initiatives with the right team members at the table from the start. The partnerships enrich projects, improve efficiency, and reduce duplication of work. Incorporating members from all clinical areas and creating a platform for partnership has reduced task force and committee silos.
For example, prior to our revision, we learned different groups were working to solve similar problems related to gastrostomy tube management and updating an electronic rehabilitation care plan. A strength of our model is the full capacity of the Pillar to connect all CSG members, serving as a communication hub. The teamwork and consultation happening at the Pillar level is vital to the progression of broad, impactful initiatives. Successful examples include the development and implementation of a formal escalation plan to identify clinical deterioration for early intervention, and a joint seating initiative to standardize and streamline the process of obtaining a wheelchair.
We're committed to continually and critically evaluating our structure, searching for opportunities to improve. Measuring meaningful CSG outcomes (e.g., engagement, quality of care, efficiency, productivity) is vital to demonstrating the value of CSG. Creating a culture of EBP, with mentorship and resources, supports clinical advancement and professional development and is an enduring focus for us.
Maintaining engagement and energy in CSG is important, especially in recent years with staffing and pandemic stressors adding complexity to clinicians' professional contributions. We feel that we've established a professional governance model that can promote shared decision-making for nurses and their clinician colleagues, resulting in excellence in clinical care.
1. The World Cafe. 2018. https://theworldcafe.com
2. dos Santos JL, Erdmann AL, de Andrade SR, de Mello AL, de Lima SB, Pestana AL. Nursing governance: an integrative review of the literature. Revista Esc Enferm USP
3. Guanci G. Feel the Pull: Creating a Culture of Nursing Excellence
. New York, NY: Springer Publishing Company; 2015.
4. Tickle E. Vanderbilt Shared Governance. Virtual meeting to discuss Vanderbilt's shared governance program. 2019.
5. Vanderbilt University. Shared Governance. Vanderbilt University Medical Center. 2019. www.vumc.org/shared-governance
7. Seattle Children's. Nursing Leadership and Governance. Seattle Children's Hospital. 2022. www.seattlechildrens.org/careers/nursing/leadership-and-governance
8. Cincinnati Children's. Pediatric Nursing; Interprofessional Shared Governance Model. Cincinnati Children's Hospital Medical Center. 2022. www.cincinnatichildrens.org/careers/ped-nursing/shared-governance
9. Massachusetts General Hospital. Collaborative Governance. Massachusetts General Hospital. www.mghpcs.org/ipc/programs/committees/index.asp
. Accessed March 2019.
10. Porter-O'Grady T. Researching shared governance: a futility of focus. J Nurs Adm
11. Weston MJ, Meek P, Verran JA, et al. The Verran Professional Governance Scale: confirmatory and exploratory analysis. J Nurs Adm
12. Porter-O'Grady T, Clavelle JT. The structural framework for nursing professional governance: foundation for empowerment. Nurse Lead