As a consultant working with health care providers on designing, implementing, and measuring the effectiveness of shared governance, it is my role to implement evidence-based management strategies that work and make a difference. As Hess (2004) points out, although there is more research to guide practice now, major questions related to shared governance remain unanswered: What does shared governance cost? Do staff nurses understand their role in shared governance? Are staff prepared (either in school or on the job) to function in shared governance cultures? Are managers prepared to lead and manage in shared governance cultures? What outcomes will be realized?

I would argue the easy part of implementing shared governance is creating the structure. Convening a group of staff nurses and nurse leaders to define the role and scope of councils, while at times arduous, is the first straightforward step. Designing and implementing both the councilor and congressional models afford a tremendous opportunity for nurses to explore and examine their beliefs about their practice, their role in patient care, and their role in creating a positive, effective, and efficient work environment. The first step is the easy one.

Much more challenging is working with staff RNs to change their behavior and attitude about their role in patient care and unit operations. As Hess (2004) points out, "Shared governance is more than a new organizational chart or committee configuration..." (para. 10). Shared governance is about staff playing an active role in unit operations. Staff nurses need to understand it is their right and professional obligation to participate in how decisions are made about nursing practice. Often staff nurses are confused about what they have the power to change. This is particularly true in facilities that have an entrenched, bureaucratic, medical model of care delivery. The adage about asking for forgiveness rather than permission is important to support as staff develop leadership skills.

Communication is another challenge. Staff leaders struggle to work with colleagues who have not paid attention to verbal, written, and electronic communication about what shared governance is, how shared governance works, and why it is beneficial to nurses and to patients. Likewise, teaching staff nurses how to prepare meeting agendas, record meeting minutes, understand group dynamics, and come to consensus on decisions are skills not typically taught in school. Finally, active, abundant communication from and to staff while councils are being established and operating policies devised, at the department and unit levels, is critical to success. Communication is time consuming if done right and well; it is more difficult than establishing the structure.

Also challenging is teaching unit managers how to lead and manage in shared governance environments. Often it is difficult for managers to give up control of those functions that traditionally were in their scope of responsibility. Working with managers so they understand their own change style, decision-making style, and leadership style is an important part of their journey of self-discovery. The journey from autocratic leader to democratic leader is not always an easy one. Equally important and challenging is working with managers to establish methods to measure shared governance outcomes at the unit level. The manager’s learning curve is as steep, if not steeper, than the staff learning curve.

Considering the challenges inherent in implementing shared governance, it is essential that we find ways to measure the benefits of shared governance. Much of the early research on shared governance was limited within scopes and quality. The nurse executive who could persuade the CEO to implement shared governance with no financial, patient, or staff outcome data was fortunate indeed. Today, those considering implementing shared governance still find a paucity of data on the costs and benefits (the most recent cost-benefit analysis was published in 1993). But fortunately, with Hess’ important work that devised a tool to measure shared governance, nurse executives and consultants have a means to establish a baseline and document specific improvements in how professional nurses participate in decisions related to patient care and the work environment. The Index of Professional Nursing Governance (Hess, 1998) has opened many doors to understanding the impact of shared governance. We now have a means to link the shared governance intervention or "treatment" to patient and staff outcomes.

As more and more organizations implement shared governance, we must understand how shared governance impacts and influences staff, patient, and financial outcomes. The challenges of implementing share governance remain, but the journey is less bumpy now that we have a means to measure, and therefore understand, the impact of shared governance.

Author

Beth A. Brooks, PhD, RN, CHE
e-mail: brooksbe@att.net

Beth A. Brooks, PhD, RN, CHE, is President, The Brooks Group, Inc. and Assistant Clinical Professor and Coordinator of the Graduate Program in Nursing Administration, College of Nursing, University of Illinois at Chicago. Dr. Brooks has more than 17 years of experience in health care including work redesign initiatives involving point-of-care documentation, professional practice model development, and shared governance implementation, as well as competency-based orientation and staff development programs. She also has experience in recruitment advertising, working with health care clients across the country on award winning advertising and marketing programs. She is board certified in health care management and a Diplomate of the American College of Healthcare Executives.

References

Hess, R. (1998). Measuring nursing governance. Nursing Research, 47(1), 35-42.

Hess, R. (2004). From bedside to boardroom: Nursing shared governance. Online Journal of Issues in Nursing, 9(1), Manuscript 1. Available: www.nursingworld.org/ojin/topic23/tpc23_1.htm.

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