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Strengthen Shared Governance Hospitalwide

 |  By  
   June 29, 2010

When Athens (GA) Regional Medical Center (ARMC) implemented shared governance five years ago, the initial drive of the program was met with different levels of success. Unit councils excelled in some areas and struggled in others, leading to inconsistent results.

The organization decided it was time to change that-and it pursued clear data to back up its decision-making process.

"We saw varying success, especially in our unit councils," says Nancy Arata, RN, BSN, MBA, from the ARMC Office of Professional Excellence. "We wanted to be able to determine if there were particular factors that influenced our success."

Based solely on gut reaction to existing success rates, ARMC's nursing leadership could see that some unit councils were outperforming others, with great results and projects coming out of the units. One of those great results: higher nursing satisfaction scores.

"Our question was, 'Could having a productive unit-based council correlate with high nurse satisfaction? Are you going to have happier nurses in units where nurses are making decisions?' " says Arata. The leadership team decided to look for evidence proving or disproving the theory-and that meant conducting a research study.

Looking for evidence
The team developed a survey and distributed it to the unit-based council members and chairs. The 11-question anonymous survey included an area where respondents were asked to list specific decisions made from the previous year.

The survey also looked at how long the council had been in existence, whether it had an elected chair, how involved the director of the unit was in the council, and whether he or she acted as a mentor.

"When we asked them to give a number of decisions they had made in their unit council, the results were really interesting," says Arata. "Some units couldn't come up with a number or list out the decisions that had been made. But others could be very specific about these things."

Based on these results, the researchers scored each unit. The scores were then correlated with nurse satisfaction survey results.

"We saw a correlation between the number of decisions the unit council had made and nurse satisfaction-it confirmed what our gut feeling was telling us," says Arata.

Once the data were correlated, researchers rated existing councils using three levels of maturity:

  • Beginning: early stages; not yet making decisions and/or purpose not clearly realized
  • Competent: capable of making change but still encountering barriers at times
  • Mature: fully developed; making clear decisions on a quarterly basis that impact nursing practice, work environment, or quality


Interestingly, the actual lifespan of the council-how long it had been in existence and functioning-didn't correlate with nurse satisfaction. What came into play was the council's own sense of its maturity-for example, councils that felt they were just starting out tended to have beginning-level scores, regardless of how long they had been in existence.

Another determining factor: If the unit director coached the council-"coached" being the operative word, rather than "directed"-the unit tended to have higher satisfaction scores.

"There was a definite correlation between the number of decisions the councils had made and RN satisfaction scores," says Arata. "If you feel like you have the authority to make decisions to impact patient care and your work environment, our study showed a correlation between that and nurse satisfaction."

Focus groups
The next step upon correlating the data was to reach out to council members and leaders to get feedback and input in real time. This meant organizing focus groups.

These sessions were mandatory for every unit chair and leader. The organizers, however, were gracious in scheduling the meetings to make sure they would work well for attendees by using multiple dates, including in the evening.

"It's hard to get away from the bedside, but if you take that time to have a conversation and gain a deeper understanding of the shared governance process and outcomes, you will see it is worth it for the patient," says Arata.

"There were about 10 people in each group, and we gave lunch passes to those who attended," she says. "We had conversations: 'What is working on your unit? What isn't? What is frustrating? Where are your barriers to improvement?' "

They also asked these groups about how management and leadership helped encourage decision-making and change.

"We took that information, along with the research study, and totally revamped our nursing governance structure," says Arata. At the organization and unit level, this meant reeducating leaders. The organization provided what amounted to a shared governance 101 program, with the thought that since the program had been in existence for half a decade, it was time to revisit its core.

"Why is this important? What is its purpose? What can it impact?" says Arata. "It's ultimately about patient outcomes, and that is impacted by nursing satisfaction, and higher nurse satisfaction leads to higher patient satisfaction."

This revamp looked at specific ways to improve accountability in the process. Every nursingwide unit-based council now has a standard template for tracking progress.

"It's a simple form that allows them to track who is coming to meetings, percentage of participation, action items, decisions made," says Arata. "They submit that to nursing administration. One of our nursing councils is the leadership council, made up of formal and informal leaders. They look at these reports."

This is not a "g

otcha" process-the leadership council takes note and praises good work, and the reports are published internally so various units can learn from each other and their individual successes.

"If, for example, surgery is doing great work on preventing central line infections, other units can look at what they've been doing and learn from them," says Arata.

On the other hand, if leadership finds that a unit is not making decisions, it has an opportunity to contact that unit's chair and ask how it can help and what barriers the unit is struggling to circumvent. Leadership provides tools and education to help make the unit council ready to take the next step in decision-making.

"We want our units to be innovative," says Arata.

The new structure
Specific changes to the shared governance program took effect in January. ARMC plans to resurvey in October to collect data on the results of these changes.

"We're hoping to have strong data from that," says Arata.

In the meantime, however, there are signs of great successes throughout the organization.

"One of our units started this process on their own a year ago," says Arata. "They revamped all of their unit-based councils so that they got everyone in the unit involved in a council."

Apparently involvement leads to satisfaction-this unit was surveyed recently and was found to be in the top 10th percentile for the nation in nurse satisfaction. "They have some of the highest nurse satisfaction scores in the country," says Arata.

This confirmed the results of ARMC's research. "We'd done our research study, and this particular unit had already started making changes," says Arata.

There were lessons learned along the way, as well. "We definitely would have had the accountability part in place five years ago," says Arata. "It's a big part of the work we're doing."

Also, don't be afraid to reeducate your staff. "It's never too early to go back and reeducate everybody," says Arata. "Everyone had been educated at some point in time. We had a workshop in November but decided it was still important and necessary to get people into small groups."

The workshop was attended by more than a hundred nurses, but breaking them into smaller groups-where people were more likely to open up, make suggestions, and speak their minds-was an even more effective educational tool.

"Looking back, we would have done those sharing sessions sooner," says Arata. There was a learning curve. Initially, nurses were nervous about updating or changing the processes.

"Once they start making decisions that impact the care they give, it's like a light bulb comes on," says Arata. "Especially when they see improvements that they were a part of creating. That's when the nursing staff really can embrace the whole philosophy of shared decision-making."

This article was adapted from one that originally appeared in the July 2010 issue of HCPro's Advisor to the ANCC Magnet Recognition Program®, an HCPro publication.


Rebecca Hendren is a senior managing editor at HCPro, Inc. in Danvers, MA. She edits and manages The Leaders' Lounge blog for nurse managers. Email her at

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