The notion that professional nurses should be engaged in shared governance within health systems is not new. Since the early 1980s, forward-thinking nurse visionaries, such as Timothy Porter-O'Grady, SueEllen Pinkerton, Robert Hess, and others, have pioneered the concept and provided sage advice on structural support for nurses to lay claim to professional practice that would drive clinical excellence. As an increased number of organizations embraced the American Nurses Credentialing Center Magnet® Recognition and Pathway to Excellence Programs in the mid-1990s, the core tenets of collaboration, leadership, professional development, quality and safety, inquiry, and evidence-based practice solidified to become even more commonplace, most often visible through councils and committees. The application and acceleration of nursing theory and science clarified nursing's contribution to the health team, increasing its stature with clinical knowledge, and enriching decision making in organizations.
Through a professional development lens, now is an apt time to ask, “What impact has shared governance had on top-down and bottom-up leadership development?” “Has shared governance led to active shared leadership within health care?” and “Would frontline staff acknowledge shared governance as responsive to their emerging issues?” The answers to these questions form the bedrock for evaluating the core of shared governance: Are nursing voices being heard, and as important, are they sharing in decision making? These questions also are useful to assess whether the individuals who provide professional development and coordinate Magnet and Pathway to Excellence programs are optimizing their talents by modeling accountability for their share in the shared governance outcomes and not just for the tasks assigned to coordinating shared governance.
From Shared Governance to Shared Leadership
At the onset of the shared governance movement, providing a forum for nurses to have a voice within the paternalistic and physician-dominated health system was a foreign idea. Particularly in hospitals, where physicians demanded and controlled a separate leadership structure from the hospital's organizational structure and no comparable mechanism for nursing input into practice changes. In retrospect, many of the early nursing councils mimicked other administrative and medical structures in some manner—those traditional hierarchical structures already in play within the hospital. In nursing, one idea was decidedly different: governance was a shared responsibility, not a unilateral function of hospital administrators or of physicians, each in potential competition with the other. From nursing theory, the idea that governance is holistic and could unify clinical strategies set in motion a lineage of interprofessional best practices, attending to organizational culture, patient engagement, and outcomes.
Currently, shared governance is being supplanted by the concept of shared leadership. The idea shifts emphasis primarily from the decision-making councils and committees where the work of shared governance takes place, to the quality of individuals acting as leader representatives, with leadership not being an ascribed as an organizational title, but as a professional attribute ascribed to all nurses. Despite the presence of councils and committees, there is no shared governance without nurses who will champion using their voice in constructive ways to effect collective and standardized patient care interventions spanning an organization. Shared governance is not only a communication structure, it is a professional decision-making mechanism, and decision making and direction-setting are leadership functions.
Moreno, Girard, and Foad (2018) reported that the council structure within their organization revealed communication lapses, lack of clarity surrounding how unit-based problems were addressed, and how these problems were turfed through their council structures. They further reported that meeting agendas were dominated by information giving rather than decision making aimed at improved patient care; further, the number of staff nurses involved in the council or committee structures lacked diversity and inclusiveness, with only 25% of participants regularly attending. To see such an honest self-appraisal reported is refreshing, advisable for all engaged in shared governance, and essential to advance the foundation of shared governance, particuarly in a multi-generational workforce.
Valuing Mission Boundaries
Shared governance and shared leadership have boundaries in focus. The mission of patient care is best accomplished by enacting a care delivery model which specifies a professional scope of practice and—often missing—responsibilities for how professionals intersect with standardized patient care processes, such as at the interface of patient education, medication procurement and administration, discharge planning, and the like. Missing from most position descriptions and shared governance councils are process improvement accountabilities that undergird systematic behavior—how nurses perform and their accountability to design thinking. A care model is more than a pictorial description of broad based values, it must embody roles and standards of care uniformly cross organizational boundaries and units of service. Within the shared governance mission should be processes for professional development and peer review both for nurses and, increasingly, other provider disciplines who provide direct patient care. The shared governance mission should also address safety standards, both minimum and desired practices to mitigate patient risk. It is this sweet spot—capturing energy to plan and project that animates shared governance, coupled with persistence and pragmatic attention to current practice problems is the leadership aim in a shared governance culture.
It should be acknowledged that the patient care focus of shared governance does not delimit nurses from sitting at other decision-making tables, such as when decisions are being made about patient billing, purchasing, or finance. These interprofessional functions require collective, rather than unilateral decision making and are rightfully seated at the periphery of practice. Said differently, patient care providers may bring clinical insights into decisions that lie on the periphery of practice, but do not have specialty expertise to solely set the direction for all aspects that comprise complex organizations. Nor would it be wise to do so.
When articulating the goals and objectives of shared governance councils, there should be evidence that the focus is directed toward patient care and outcomes, with a heavy emphasis on decision making. Moreno et al. (2018) noted that it is plausible that 90% of clinical decisions can be made at the unit level, with 10% reaching the cross-cutting patient care services served by representative councils. In academia, shared governance focuses on curriculum, which affects student learning and faculty development to ensure optimal teaching–learning. In practice, shared governance addresses patient care design and the delivery model, with the aim to ensure safe and effective patient care outcomes. Once again, recall that if shared governance councils soley exist as a communication structure there is no governing taking place. Governing requires decision making. Specifically, governing focuses on intentional and high-impact clinical decision making that spans nursing services regardless of where nursing is practiced within an agency.
Councils as a Leadership Development Opportunity
Shared governance requires a mechanism to bring professional nurses together for engaged decision making. Council structures sometimes look eerily alike between organizations and are usually organized around quality and safety, professional development, research, and units-based practice all reporting to a higher level oversight council. No doubt that council and committee structures look similar because Magnet standards identify the functions to achieve Magnet status, creating a reticence to derive alternate structures that might jeopardize recognition.
Whatever the council structure, the professional development opportunity is what happens within these councils. Each counsel should promulgate skills in leadership—how to set agendas, how to prioritize and standardize care, how to examine decision making beyond consensus decisions, how to message critical communications, and how to consider emerging trends, issues, and clinical evidence proactively to prepare for new patient service demands. Rather than setting up agendas under the headings of old business and new business, it is apt in today's practice environment to consider agenda items that start with high impact issues, followed by items with low impact. This shift respects where mission-critical input is needed, offsets informational-only items, and models the best use of the representative voices at the table. Rather than consensus decision making which is based on compromises, shared governance should lead instead to optimal decision making, whereas what is best for patient care and the organization is achieved. Meeting agendas are also advanced when the meeting focuses not only on high-stakes thorny problems, but also has room to address future trends and issues and the proactive practice implications that will require decision making at a future time. Rather than succumbing to how each unit or service line is unique and different, council leaders learn the skill of looking for the similarities that cross boundaries.
The Future of Shared Leadership
Shared governance will remain relevant as long as nurses embrace leadership in organizations. It will remain relevant if Magnet reviewers examine the core principles at play, coaching organizational leaders beyond using shared governance primarily as a communication mechanism, as noted earlier. It will remain relevant if professional development educators commit to using it as a forum for leadership development, expending time, effort, and considerable talent to develop accountability-oriented practitioners, who use their voice on mission-centered matters. It will remain relevant if those who hold formal leadership titles shed command and control models. It will strengthen when multigenerational and developmentally committed nurses come together, not to protect and defend their specialty unit, but rather to embrace a world view of nursing across service lines and also extend into the community.
- Moreno, J.V., Girard, A.S. & Foad, W. (2018). Realigning shared governance with Magnet and the organization's operating system to achieve clinical excellence. Journal of Nursing Administration, 48, 160–167. doi:10.1097/NNA.0000000000000591 [CrossRef]