Involving Nurses in Shared Decision-Making

We should listen to nurses, said the Robert Wood Johnson Foundation recently, which teamed with Gallup to survey opinion leaders from a variety of industries on nursing's influence. While noting that nursing is one of the most trusted professions, this trust does not translate into action, the survey found. Nurses have less influence on healthcare reform than government, pharmaceutical, and insurance executives.

My colleague, Janice Simmons, covered the survey in detail here. The stark portrayal of nursing's voice in big picture, national issues got me thinking about day-to-day issues, and whether nurses have a place at the decision-making table in most healthcare organizations.

Union leaders argue that all too often they do not, and that unions should be the ones to provide the voice. Some organizations ensure nursing's voice is heard and that nurses are involved in all decisions through shared governance.

Shared governance models—such as those developed by Tim Porter-O'Grady—turn traditional hierarchical structures into flat, decentralized systems where decision-making lies with stakeholders (i.e., nurses at the bedside), rather than with senior leadership.

One organization that practices this model is the Lehigh Valley Health Network, based in Allentown, PA, which has had robust shared governance since the 1980s that gives nurses a voice in determining nursing practices, standards, and quality of care.

"To us it means that all staff have the responsibility and are held accountable for decisions that impact their role," says Kim Hitchings, RN, manager of the Center for Professional Excellence at Lehigh Valley Hospital, and a national speaker on best practices for adopting shared governance. "It's not just staff nurses; it's also nurses who are in management positions, or unlicensed assistive personnel. In this organization, we believe everyone is responsible for decisions that impact their role and responsibilities."

At LVHN, this means that nurses at the bedside are empowered to make decisions about the practice of professional nursing. And Hitchings says it results in a nice place to work, evidenced by the fact the hospital has been on Fortune's 100 Best Companies list for three consecutive years. When ranking the health system, Fortune noted the robust culture of involving staff in decision making as a prime reason for making it on the list.

LVHN's structure has been in place long enough to self-measure success. Six components are involved:

1. Practice: Nurses make decisions about their practice, rather than having decisions announced from above. For example, a night-shift staff nurse attended the Academy of Medical-Surgical Nurses annual conference, where she heard about a bedside shift report process that she thought would benefit her unit. So she researched the process and brought the idea to her unit's practice council, where it was collectively decided to implement bedside shift reporting. It is now being implemented house-wide.

2. Quality: Individual units have quality improvement councils and metric boards showing quality indicators are displayed in public areas so that all staff, visitors, and patients see data relating to pressure ulcers, patient falls, etc.

"Staff know their unit's scores and analyze the data," says Hitchings. "For example, if a patient fall occurs, staff on that unit will sit down and do a root cause analysis and then create an action plan on how to prevent similar falls in the future."

3. Evidence-based practice and research: "It is the responsibility of the organization to not only have the structures in place, but if you want a robust shared governance model, you have to provide resources for nurses to then do it," says Hitchings. Nurses at LVHN base their practice on evidence, have councils to consider evidence when weighing practice changes, and regularly initiate research projects to determine for themselves the answer to clinical questions.

4. Professional excellence: The organization budgets operational dollars and utilizes donated funds for staff to attend professional development meetings outside the organization. The goal is to have at least one staff member attend every major national nursing conference.

5. Reward and recognition: The organization assigns dollars to each department, based on FTEs, for reward and recognition activities; that department then decides how to spend the money and recognize and reward its staff members.

"What you perceive as reward and recognition may not be perceived by someone else as reward and recognition," notes Hitchings. "Our staff on each unit decide what's important to them."

6. Operations: To many nurses, control over their schedule is a priority. "They work out and determine how they do their schedules," says Hitchings. "One unit will have one way to decide who works Christmas and another unit will do it differently. But it's not decided by a director or some central process or even electronically. Nurses determine the guidelines and create the schedule themselves."

Similarly, staff are involved in the hiring process for managements positions and peer interviews when staff nurses are hired.

Hitchings says shared governance is an important part of life for her organization and she can't imagine nursing not being involved in decision making. "Our senior leadership and middle management recognize the value from staff being involved in decisions," says Hitchings. "And we all recognize the impact it has on staff, and ultimately patient, satisfaction."