Staff Nurses' Perceptions of Nurse Manager Caring Behaviors
As healthcare administration becomes more complex and financial challenges continue, the ability of nurse managers to lead patient care environments that...
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by Deborah Brennan, DNP, RN, RNC-OB, NE-BC + Lori Wendt, BSN, RN
The shared governance structure is a nursing practice model which is a hallmark of engaging the front line team into the role of leading practice excellence. The main principles of shared governance include ownership, accountability, empowerment, team building, leadership, innovation, autonomy, and practice equity. Combining these key shared governance principles with formal models can drive sustainable action planning for improvement. This article offers an exemplar describing how we improved shared governance in a community hospital setting. After evaluating findings from a gap analysis, we incorporated guiding frameworks such as the A3 action planning process; the Plan, Do, Check, Act cycle; and Lean methodologies to increase nursing engagement in the shared governance process. Clinical nurses and interdisciplinary teams developed action plans for quality and patient satisfaction improvements. We describe specific improvements to our process, offer examples of our improved outcomes, and discuss essential shared governance factors that were critical to our successes.
What is shared governance and why is it important? What role does shared governance play in our practice? How do we apply best practices within the shared governance framework? These are questions often pondered by nursing teams. Buzzwords like “shared governance,” “interdisciplinary teams,” and “multidisciplinary collaboration” are often used in discussions. These words can imply that integrating a shared governance model framework will automatically lead to improved collaboration and employees will become more engaged in the workplace. However, lacking a clear vision of a workable shared governance model, many organizations may struggle with not only implementation, but also integration and sustainability of this process as well. Conversely, a thoughtful shared governance model will often result in a robust interdisciplinary team with clinical nurses driving changes over time.
...most organizations fall short by failing to consider long-term sustainability Key to a successful shared governance model is the support of unit level councils in the organizational structure; most organizations fall short by failing to consider imperative structural factors (Ballard, 2010). These councils depend on leadership support through development of leaders who oversee the shared governance councils, and staff engagement in the process. Even after establishment of a successful shared governance model, barriers may include autonomy and empowerment or other factors along with providing the councils with the resources needed (Ballard, 2010). This article offers an exemplar describing how we improved shared governance in a community hospital setting. We describe specific improvements to our process, offer examples of our improved outcomes, and discuss essential shared governance factors that were critical to our successes.
Shared governance is a working model of participatory decision-making... Shared governance is a working model of participatory decision-making in which nurses and the interdisciplinary team follow an organized decision-making process about practice standards, quality improvement, professional development, and research leading to improved outcomes and shared success (Winslow, Hougan, DeGuzman, & Black, 2015). It includes shared accountability, shared vision, collaborative partnerships, and focuses on outcomes leading to shared success. Alignment with hospital policies, the nursing professional practice model, organizational strategic plan, and fiscal responsibility is essential. The use of a professional practice model and shared governance model are supportive frameworks. Although it can be seen as a nursing model, shared governance is an interdisciplinary process in which various disciplines from across the hospital identify issues and collaborate to determine solutions (Winslow et al., 2015).
A universal understanding of what the shared governance process means to each nurse and the team is pivotal to ensure that everyone speaks the same language. The shared governance process has been defined as a multifaceted concept that encompasses the structure for members to participate in the decision making process and goals of the organization (Hess, 2017). Shared governance is participatory, by definition, with a defined structure and developed process that enables relevant and meaningful outcomes. The ability to follow a standardized process facilitates improved outcomes, a mechanism to share achievements, and opportunity to spread best practices.
The most common benefit of shared governance is empowerment. The most common benefit of shared governance is empowerment. A nurse and front line team-driven model is a practical and structured approach (Owen, Boswell, Opton, Franco, & Meriwether, 2017). Crucial factors include creating and supporting a process that allows room for innovative practices; this prevents stagnation, encourages growth, and leads to productive value-added outcomes. The bottom line is that the team embraces changes that affect them as a part of any process in which they are invested.
Brief Summary of Our Process
The discussion of shared governance in this article describes the process at a suburban community hospital with approximately 200 beds. The hospital employs about 550 clinical registered nurses (RNs). There are over 30 RNs who serve on the hospital shared governance council. Our structure includes more than a dozen unit level councils that represent areas such as medical-surgical care, critical care, and community outreach. These smaller unit councils typically include 6-12 nurses per council and include other disciplines and roles in attendance.
These steps facilitated greater engagement and understanding about the improvement process... Our hospital realized the necessity to establish a more robust and integrated process to ensure the success of our shared governance councils. We completed a gap analysis and the initial outcomes suggested changes such as an updated meeting cadence and template for the meetings; adopting a formalized “Plan, Do, Check, Act” (PDCA) action plan; and integrating additional improvements (Ghosh, 2012). The PDCA cycle provided a sequential step by step process to evaluate, analyze, strategize, set goals, plan, and appraise effectiveness. These steps facilitated greater engagement and understanding about the improvement process, and led to the productive and meaningful outcomes described in examples below. We also included an evaluation of the council process; meeting format and content; impact and outcomes.
Our purpose was to align with the mission, vision, and values of the health system and hospital and its strategic plan. Our aims were to encourage greater clinical nurse involvement and to improve outcomes in general. Examples of specific targeted alignment and strategic planning engagement included focused shared governance work to improve patient satisfaction scores; improve RN-RN teamwork; and decrease patient falls. The work included seeking innovative and evidenced based approaches. Improving outcomes and processes, with collaboration, ownership and value-added work, was a primary goal.
The work included seeking innovative and evidenced based approaches The work to strengthen our shared governance model had positive outcomes. Relationship building that occurred between the teams facilitated and strengthened positive partnerships with ancillary departments. Our emphasis on the targeted outcomes, and a clearly defined process, assisted us to keep a focused approach. This section describes in greater detail the findings from our gap analysis; subsequent steps to improve the process; the flow of our shared governance model; and briefly describes several of the formal models that guided our work.
The Gap Analysis Findings
A gap analysis...revealed specific areas for improvements A gap analysis of the hospital nursing governance council and unit governance councils revealed specific areas for improvements. The nursing governance council and unit governance council groups are mainly comprised of clinical nurses and included interdisciplinary members. We found the following concerns:
After completing the gap analysis to determine the site shared governance needs, it was discovered that our current shared governance model was lacking meaningful engagement to support the mission, vision, and values of nursing and our organization.
Next Steps
...they decided it was essential to complete a thorough review of current projects and establish future goals Improving Engagement. We devised a plan to empower and re-engage our nurses. Meetings with the members of the clinical nursing governance council chair and our Magnet® Program Director encouraged everyone to brainstorm ideas to present to the nursing governance council. Together, they decided it was essential to complete a thorough review of current projects and establish future goals. Everyone wanted to establish a vision and direction for the future. This process resulted in clear goals to articulate what the future state would “look like, feel like, and be like” on a personal level for the individual clinical nurse, the team, and more importantly, the patient.
The nursing governance council met monthly for several months to coordinate, review, and revise the nursing governance council structure and process. Members of the nursing governance council took an honest look at actual and perceived limiting factors. They formed plans driven by the collaborative conversation that took place during these structured meetings.
Action Plans. Once the team responded, facilitated action planning began. This was when we realized improved engagement in the process. Nurses became excited about the work, were able to visualize their impact, and thus engagement increased. We carefully ensured that council members felt the work was value added, produced change, and was meaningful. The ability to create and implement action plans kept the team focused in their approach. Recognizing success and highlighting the collaborative contributions of the teams were primary goals as we developed our shared governance model. Flexibility gave the nurses the freedom to adapt, abandon, or adopt the initial practice or process change. Nurses were encouraged to embrace change and try new approaches within a supportive structure.
Nurses became excited about the work, were able to visualize their impact, and thus engagement increased Better engagement spread from the initial successful nursing governance council to those at the unit level. Nurses were a part of the evaluation of data; current state of the problem; current practice; barriers; goal setting opportunities; and plan for implementation. In sum, we used specific, measureable, actionable, relevant, and timely SMART goals combined with a clear definition of who was responsible for specific interventions and a timeline to support ownership and accountability.
Improved Data Review. As a part of the action plans, we reviewed data from various healthcare metrics (e.g., National Database of Nursing Quality Indicators [NDNQI]; Hospital Consumer Assessment of Healthcare Providers and Systems/Press Ganey percentile rankings) during monthly meetings to discuss process improvement initiatives. Many of these metrics were new to the clinical nurses and teams were engaged in the work. This monthly review was followed by evaluation and then adjustment of the action plans during the meetings.
Many of these metrics were new to the clinical nurses and teams were engaged in the work. One challenge was ingraining the cadence of the monthly data review in meetings at all levels. Eventually, the shared governance councils became more knowledgeable and staff could discuss the process and outcomes. This progress led to a dynamic shift in positive engagement in the process. Nurses felt empowered and embraced the goal to improve the workplace environment and culture. Each unit governance council adapted their plan based upon unit specific needs, the patient population, or other factors. The action plans created by the nurses and staff at the unit level were supported by their nurse leaders. Eventually we adopted a set cadence for meetings that utilized an agreed upon, formalized agenda template.
Nurses proactively engaged colleagues from other disciplines and departments... Other Process Improvements. Councils have the option of teleconferencing to encourage increased participation. Nurses proactively engaged colleagues from other disciplines and departments by inviting them to attend the meetings. This outreach created the opportunity for discussion and collaboration on items that affected more global level practice and workplace initiatives that, in turn, impacted nursing. The next barrier would be sustainability and communication. To support ongoing work and improve communication, each meeting concluded with three key takeaways to share; this agenda item was formally added to the meeting template.
Shared Governance Flow
Information in our shared governance process flows from the councils to the practice areas. Feedback is then filtered back to the appropriate councils. Giambra et al. (2018) recommended setting goals with review throughout the year, and we follow this process.
Work is completed at the unit or local level whenever possible. An example of this is the role of the councils and addressing staffing changes. A true test of the councils occurred when hospital leadership adjusted staffing ratios in response to budgetary factors. The determination of appropriate staffing ratios relies on many factors that are not within scope of the shared governance council. Thus, the team’s focus became the impact of interventions to reassign non-nursing patient care activities; current processes to decrease non-value added functions; the ability to work at the top scope of their nursing license, and improved efficiency in care.
The shared governance councils were very active and vocalized their many concerns with the staffing changes that were implemented. Through ongoing collaborative discussions, our nurses were able to influence their environment in response to these changes in the following ways:
Work is completed at the unit or local level whenever possible.The nursing governance council became further invested in this process by providing feedback about policies and also created, revised, or developed new policies. The nurses worked on specific staffing policies related to reassigning (pulling) nurses to another unit and shift staff cancellation. Efforts and input from clinical nurses drove the changes as they collaborated with nursing leaders.
Guiding Frameworks
Several formal models guided our shared governance process. The ability to have greater autonomy and support leads to greater empowerment through a structured process (Moreno, Girard, & Foad, 2018). The use of standardized process and expectations supports the shared governance process (Giambra et al., 2018). Several formal models guided our shared governance process. This section will discuss each of these briefly.
A3 Action Plan. The nursing governance council chose to adopt the A3 action planning process (Ghosh, 2012). Fortunately, the use of A3 was already in place within our organization, which made it easy for the nursing governance council to adopt. The steps of the A3 action planning cycle ensured that new ideas and processes could be trialed and integrated along with an evaluation of the new processes.
The A3 plan describes the who, what, when, where, and how steps on one sheet of paper. The A3 approach is a problem solving and improvement process from the LEAN methodologies work at Toyota. The term A3 was derived from the standard size of paper in which the structured continuous improvement process can be defined and tracked. Engaging frontline team members in the development and planning process can support increased empowerment and engagement (Ghosh, 2012). Using the steps of the A3 action planning process, we examined the following:
The steps of the A3 action planning cycle ensured that new ideas and processes could be trialed and integrated along with an evaluation of the new processes.
PDCA Cycle. The nursing leadership team and chief executive officer supported the process and provided mentoring or resources as needed. In our A3 action planning process, we incorporated the benefits of the Plan, Do, Check, Act (PDCA) concepts into the format (Ghosh, 2012). The Plan process includes documenting the problem, background, current state, problem analysis, targeted outcome, and creating implementation steps. The work completed during the implementation steps and the results are the Do phase. The Check process includes reviewing the results and evaluating effectiveness. The Act steps include the final process of standardizing and spreading of the best practice (Ghosh, 2012).
Lean Methodology. Lean methodology is a process which evaluates the purpose, people, and process to understand and improve the value and continuously improve (Lean Enterprise Institute, 2020). The use of Lean methodology is focused on customer value and respect for the person. We incorporated concepts from this methodology into our shared governance process integrating the PDCA process with Lean methodology and used the A3 problem solving template to guide work. We also reviewed monthly the action plans which included current data. During the review we would update or change the action plan, if needed. Project examples include the relocation of equipment at the point of care and decreasing the waste in the process stream in regard to caring for the stroke patient upon admission in the emergency room. The elimination of steps in a process while caring for stroke patient led to decreased door to needle time and improved care.
In the next section, we discuss factors important to the shared governance model in general, and include information that we learned during our evaluation of our work about how these factors were a part of our specific process. Specific ways that we evaluated are worked to have a more rigorous shared governance model included the use of the above methods in a standardized focused approach. We evaluated our shared governance process monthly and updated as needed based upon feedback from the council. This led to increased engagement and a structured process.
Shared Governance Factors and Our Successes
Ownership and Accountability. Ownership is the recognition and acceptance of the impact and contributions of everyone’s individual and collective work. Everyone must commit to investing in the process and owning their contribution(s) to the workplace (Swihart, 2011). Nurses are very familiar with the concept of ownership. For example, nurses have “their assignment” and “their patient.” Translating this to shared governance by way of “their practice” is a natural progression of this concept.
Nurses are very familiar with the concept of ownership. Mature nursing practice is driven by accountability. Accountability is defined as a willingness to take ownership of practice decisions which support partnerships, leading to improved outcomes (Porter-O’Grady, Hawkins, & Parker, 1997). Accountability is further developed and supported within an outcome-based review, by embedding actions within practice roles and providing a collaborative environment that supports and fosters teamwork. Collective and personal accountability are critical for shared governance success.
The accountability piece can be the more difficult aspect of the process. Nurses traditionally do shift work; when the assignment or shift is over, their accountability ends. Seeing their work as their practice, continuing beyond the immediate tasks, takes time. But, without the key concepts of ownership and accountability, a shared governance model may fail.
The accountability piece can be the more difficult aspect of the process. In our setting, nurses drove practice changes and were accountable for their practice at the unit and organizational level. They developed the teams, via the shared governance model, and individuals were able to see how ownership and self-accountability contributed to and affected outcomes and the culture. Nurses began to own their practice. For example, they reviewed evidenced based practice and research literature and developed a plan to implement changes. The plan included evaluating current data; reviewing current processes and barriers; implementing changes; ownership for interventions; and monthly evaluation of outcomes. Clinical nurses began to actively seek projects and evaluate data, instead of waiting for it to be posted for their units. They advocated for change and self-identified new projects and processes to improve.
Empowerment and Team Building. Empowerment depends upon partnerships; it is value driven and everyone shares in the process. Empowerment is defined as the authority and autonomy to make decisions or influence decisions about the clinical practice (Winslow et al., 2015). Empowerment can also be defined by the access to resources and the psychological response to the resources. (Owen et al., 2018). Teamwork and partnerships are the building blocks to the interprofessional decision-making process. Each stakeholder and member has a role in supporting and engaging in meeting the mission, vision, and values of the organization’s strategic plan and effectiveness (Swihart, 2011). If nurses are not empowered to make changes, they may lose the incentive to examine and improve their own practice.
If nurses are not empowered to make changes, they lose the incentive to examine and improve their own practice. Our nurses indicated that they were able to realize their role and impact, which led to a sense of empowerment over their practice and workplace. The ability of the team to work together collaboratively increased connections, engagement, and team work. Through collaborative efforts, seeking support, and working with others within the organization, a greater sense of teamwork, respect, and improved relationships was accomplished. A greater understanding of other perspectives, rationale, and why things were done a certain way led to improved understanding.
Leadership and Innovation. A qualitative study (Dearmon, Riley, Mestas, & Buckner, 2015) explored developing leadership in front-line nurses. Dearmon and colleagues found that the development of leadership qualities was an outcome of participation within the shared governance model. Each nurse assumed a leadership role simply by virtue of participation. Providing leadership training, tools and resources combined with mentoring led to creating an environment that fosters the development of advanced leadership qualities
Each nurse assumed a leadership role simply by virtue of participation. The shared governance process should be frontline and team-driven within a supportive framework. Nurses touch all aspects of patient care and workplace environment practices. They should be represented at the table for discussions and included in the organizational decision making process. This deep rooted involvement fosters innovation, which results from the ability and confidence to lead and seek new ideas and solutions. Innovation ignites the spirit of inquiry. An innovative mentality leads to research investigation, producing an evidenced-based practice (Melnyk, Fineout-Overholt, Stillwell, & Williamson, 2009).
New clinical nurse leaders were born and previous clinical nurse leaders were able to grow into their new leadership roles... In our organization, clinical nurses specifically demonstrated leadership and innovation by leading specific projects; becoming chair or co-chair for unit and hospital shared governance councils; engaging in system level councils, and as a result had a greater voice within the organization. New clinical nurse leaders were born and previous clinical nurse leaders were able to grow into their new leadership roles which included more responsibilities and greater influence over practice. The shared governance councils engaged in discussion about management and leadership topics, such as financial and operational issues; recruitment and retention; and required accreditation standards, to name a few.
Practice Equity and Autonomy. Equity speaks to the idea that no one role or person is more important than another. Although equity does not equal equality in terms of scope of practice, knowledge, authority, or responsibility, it does mean that each team member is essential to providing safe and effective care and should contribute (Swihart, 2011). Equity ensures that all members of the care team realize their valuable contributions to the team; it is the team that drives outcomes. The value of contribution cannot be overstated. When people feel valued, they engage in shared decision-making because they know that their voices count. Building equity in the system at the point of care leads to improved partnerships and relationship building (Bieber & Joachim, 2016).
When people feel valued, they engage in shared decision-making because they know that their voices count.Equity drives autonomy. The partnership of authority, autonomy, and accountability are key to shared governance success (Winslow et al., 2015). Autonomy can be defined as a right of condition or self-governance. Autonomy is the ability to have influence over practice and the workplace, but it only thrives in an equitable and balanced environment. Shared decision making for clinical practice and management decisions can be further defined into specific areas of responsibility (Haag-Hartman & George, 2010). For example, clinical practice accountability may include such topics as standards of practice; care delivery model; professional development; quality; peer review; and interdisciplinary relationships. Management accountability topics include allocation of resources; structure; system/organizational processes; reward; and recognition (Haag-Hartman & George, 2010).
Nurses in our organization expressed that they felt valued. They greatly appreciated the sensitivity to their opinions and inclusion with the decision making process. Individual nurses and teams became engaged within all of the areas that we addressed.
Select Organizational Outcomes
Intake and Output. The nursing governance council first created an A3 action plan for patient intake and output documentation. The council reviewed the data and contributed to the examining the ‘5 Whys’ process (Ghosh, 2012) to discover the possible root cause(s). A target goal for improvement was developed using the SMART goal format: specific, measureable, achievable, relevant, and time bound (Landau, 2018). The target and progress was reviewed monthly during every nursing governance meeting, and the nursing governance council representatives relayed the information to their unit governance councils. The outcome demonstrated an increase in intake and output documentation compliance. Organizational compliance improved from a low of 33% to 76%; several units achieved 100% documentation compliance over a 2 month timeline. The process continued and we achieved additional improvement in outcomes.
Patient Satisfaction. We worked to improve patient satisfaction percentile ranking scores. A general practice unit created an A3 action plan to improve RN courtesy and respect percentile ranking for the question: ‘During your stay, how often did the nurses treat you with courtesy and respect?’ The unit standardized the process and developed a plan of action driven by the nurses and the unit team members to ask patients how they preferred to be addressed. The results indicated that the RN courtesy and respect ranking increased from the 38th to the 60th percentile ranking.
A different unit evaluated their Press Ganey data and decided to work on an A3 action plan to improve RN listening for the question ‘During your stay, how often did the nurses listen carefully to you?’ Another plan was implemented to ask about preferences in situations that were within patient control. For example, we ask such questions as “Do you prefer the lights on or off?’ or ‘Do you prefer the door open or closed for your privacy?” Due to the work and efforts of the team, the percentile ranking for the RN listening question increased from the 16th to the 79th percentile ranking. Improved outcomes were noted with other Press Ganey patient satisfaction questions as well, including likelihood to recommend.
Patient Falls. The process was expanded to examination of patient fall data from the NDNQI database. Nurses created a global fall prevention A3 action plan at the nursing governance level. They were charged to further develop and adapt the A3 action plan at the unit level. Clinical nurses and team were provided with the hospital and unit specific NDNQI patient fall data. After evaluating the data, they created unit specific fall prevention plans for targeted patient populations. Patient falls decreased from 2.65 to 1.22 falls per 1,000 patient days and remained under the mean national benchmark. Patient falls with injury per 1,000 patient days also decreased and fell under the desired national mean.
There were many measurable outcomes and improvements celebrated by the teams. There were many measurable outcomes and improvements celebrated by the teams. The improved process provided opportunities to enhance nurse engagement and empowerment while building positive relationships with the team and other departments and disciplines. The process supported improved NDNQI metrics for nursing sensitive indicators and the RN Satisfaction Survey and through this effort, clinical nurses evaluated data and increased their knowledge about quality metrics and benchmarking. Finally, our organization has received recognition as a 5-star hospital by the Centers for Medicaid and Medicare Services, Leapfrog Grade A hospital, and a Healthgrades Outstanding Patient Experience Award (Henry Ford Health System, 2019).
The shared governance structure is a nursing practice model which is a hallmark of engaging the front line team into the role of leading practice excellence. The shared governance process is based upon the ideas of partnership, equity, accountability, and ownership (Ballard, 2010). These foundational aspects of shared governance are key elements for success (Bieber & Joachim, 2016). These core aspects were a part of our ability to align shared governance decision-making with the A3 action planning format, the PDCA cycle, and LEAN methodologies to support a more robust nurse-driven process that used structured, data driven analysis and ownership at the organizational and unit level.
The shared governance process is based upon the ideas of partnership, equity, accountability, and ownership The team shared that they felt able to focus on hospital and unit specific goals and work with the new process as they sought greater autonomy over their practice. The nursing leadership team and the chief nursing officer fully supported the work and process. This support was pivotal to the successful implementation of the process and outcomes. Inclusion of others on an interdisciplinary team was also pivotal to success. The partnership with a collaborative team decreased barriers and facilitated improved engagement, participation, and outcomes success.
Inclusion of others on an interdisciplinary team was also pivotal to success. Where are we now? We have further engaged the team but expect that there will be pockets of unit governance councils that will falter from time to time. The council has decided to examine their processes and plans on an annual basis. As with any process, there are times when practices need to be adopted, adapted, or abandoned. This spurs our spirit of inquiry into how we can be more creative, innovative, and evidenced based in our approach. Questions that we now ask include: What are others doing? How can we do it better? What new way can we approach the problem or change the process? At whatever point we are in the shared governance process, the guiding philosophy is empowerment for nurse driven change on the frontline.
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The shared governance structure is a nursing practice model which is a hallmark of engaging the front line team into the role of leading practice excellence...