Running head: ISSUE ANALYSIS PAPER 1

Issue Analysis Paper

Shared Governance-Qualitative and Financial Justification
Amy Johns, RN, ONC
Ferris State University

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Abstract
This paper is a nursing issue analysis assignment undertaken by students pursuing a Bachelor of
Science in Nursing degree from Ferris State University. The topic of this analysis is a qualitative
and financial exploration of shared governance models of practice. Background for this
examination includes a brief look into a selected history of nursing staff shortages, the shortage
predicted to occur by the year 2020, and the strategies for addressing this shortage. Strategies
addressed in this paper are aimed at increasing nurse retention and increasing nursing job
satisfaction. The development of shared governance, as a practice model component, and its
implementation to address the nurse work environment issues of autonomy of decision-making,
empowerment, teamwork, and collaboration are discussed, as well as its sociologic, business,
and nursing theory base. Research providing evidence for the justification of shared governance
practice models on a qualitative and financial basis was sought and the results were analyzed.
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Issue Analysis Paper
Shared Governance-Qualitative and Financial Justification
The ebb and flow of nursing staff shortages is a complicated and multi-factorial topic.
Shortages are predicted to increase as reimbursement practices become more stringent and as
demand for nurses increases due to the nations aging population (American Association of
Colleges of Nursing [AACN], 2014; Elgie, 2007). Recruiting, educating, and retaining qualified
nurses is a challenge that will only become greater as predicted shortages occur.
One contributor to nursing shortages is nurses who leave the workforce because of
changes in the nurse practice environment. These changes are a result of reimbursement-driven
decreased lengths-of-stay, increased patient acuity, environmental safety concerns, and increased
demand for qualified nurses (Elgie, 2007). Strategies to recruit and retain nurses to staff the
high-stress nurse practice environment have been examined. One strategy is to implement
changes to institutional practice models that increase job satisfaction and address work
environment qualities determined to be relevant: autonomy of decision-making, increased equity
and professional collaboration.
Shared governance (SG) is one such model that has been widely implemented to address
those factors. The concepts of SG are rooted in sociological, business, and nursing theory and
are widespread through a variety of nurse practice environments throughout the country. The
Magnet

Certification Program was established to assess nurse work environments for core
values, nurse autonomy and engagement, safety conditions, and high standards of patient care
(Elgie, 2007).
This paper will examine and analyze the history of SG in nursing, its business and
nursing theory base, and the role of the Magnet

certified work environment. This analysis is for

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the purposes of determining the qualitative benefits of SG on the nursing work environment and
for assessment of its financial justifiability.
Shared Governance
Definition and Characteristics
Shared governance is a management model and framework utilized by organizations,
which decentralizes authority and promotes professional practices and behaviors. It facilitates
and maximizes employee engagement, collaboration, communication, and decision-making
autonomy and ownership (Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and
Allied Health, 2003; Mosbys Medical Dictionary, 2009). It is a values-driven practice model
that gained favor for its ability to address the working environment and job satisfaction of nurses,
and improve nurse retention rates (Anthony, 2004). There are four primary principles that make
up SG: partnership, ownership , accountability, and equity (Swihart, 2006).
Characteristics of SG implementation include structures (councils), processes (bylaws),
and outcomes (metrics) (Rundquist & Givens, 2013). SG models are centered on a structure of
councils that bring nurses together for collaborative decision-making process guided by
established bylaws. SG is outcome-driven and demands tangible, documentable, evidence-based
and process-driven problem solving tactics (Rundquist & Givens, 2013).
A Selected History of Magnet

Certification
There is a predicted shortage of one million nurses by the year 2020 related to several
factors, including but not limited to: workforce loss of nurses due to stressful work environment
and increased demand related to the aging United Stated population (AACN, 2014; C-White
Cumming, 2011). The Nurse Reinvestment Act of 2002 was enacted by Congress to address this
impending shortage (C-White Cumming, 2011). This act was intended to, improve nurse
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retention by collaboration with other professionals, increase geriatric nurse education, nurse
faculty loan programs and magnet facility patient safety grants to support greater provider and
care activity coordination (Premier, 2005, as cited in Elgie, 2007, para. 27).
The Magnet

Certification Program is a program born from a survey conducted by the

American Nurses Association (ANA) to discover factors that were shown to contribute to
success in hiring and retaining nurses (Elgie, 2007). These factors were determined to be, staff
autonomy, management involvement, administrative support, and sufficient staffing ratios
(Fetters-Anderson, 2003 in Elgie, 2007, para. 43). A strong component of Magnet certification
is the implementation of a system of shared governance (Rundquist & Givens, 2013).
Magnet

certification recognizes institutions for quality patient care, nursing excellence,

and innovations in professional nursing practice (American Nurses Credentialing Center
[ANCC], 2014). A study done by Clavelle, Porter-OGrady, and Drenkard (2013) shows
correlation with Magnet

certification and positive nurse practice environment with qualities

including positive nurse/physician relationships, good organizational support, and positive
patient outcomes.
The Institute of Medicine and the National Healthcare Safety Environment
Beginning in the year 2000, the Institute of Medicine (IOM) published three pivotal
documents to bring light to occurrences of medical error and the state of patient safety in the
United States healthcare system. To Err is Human: Building a Safer Health System (Institute of
Medicine [IOM], 2000) was the first document published and brought focus and attention to
safety issues. It was followed by Crossing the Quality Chasm (IOM, 2001), which presented
new and revolutionary foci of healthcare delivery, including patient-centered care. In 2003, the
IOM produced Health Professions Education, which listed competencies to be purveyed to
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students of healthcare, including: providing patient-centered care, working in interdisciplinary
teams, employ evidence-based practice, applying quality improvement, and utilizing informatics
(Yoder-Wise, 2014). These documents had an impact in on implementing practice models that
would affect the culture of healthcare by incorporating core values and focusing on relationships
between healthcare disciplines, and between healthcare professionals and patients.
The Nurse Reinvestment Act of 2002, the development of the Magnet

Certification
Program, and the pivotal IOM publications striving to initiate a national culture of patient safety
were all factors leading to the widespread implementation of SG that is seen in the healthcare
environments of today.
Theoretical Base
Kanters Theory of Organizational Empowerment
One important theory in the development of shared governance models has been Kanters
Theory of Organizational Empowerment (Anthony, 2004). Rosabeth Moss Kanter received her
PhD at the University of Michigan and is a business professor at Harvard Business School
(Hindle, 2008). Her early work was in sociology and has broad implications in her insight into
organization behavior. Her theory of organizational empowerment states that an individuals
perceived power has implications on their work behavior (Hindle, 2008). Kanters theory asserts
a correlation between an individuals perceived access to power and opportunity with increased
positive work behaviors and attitudes (Nedd, 2006). Key concepts in Kanters theory are:
perceived formal power, perceived informal power, access to resources and information, and
support (Anthony, 2004). This theory was utilized in the development of SG to address and
support the desired changes in the nurse work environment of increased equity and autonomy
resulting in increased job satisfaction and retention. A study by Nedd (2006) explores the
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question of whether nurses perception of perceived power (informal and formal) and perceived
structural empowerment opportunities were correlated with their intent to stay employed at that
job. Strong correlation was found between study empowerment variables (Nedd, 2006). This is
supportive evidence that SG increases job satisfaction and retention.
Swansons Caring Theory
Swansons Caring Theory is a mid-level nursing theory that is based upon the idea that,
caring about patients is as important to patient well-being as caring for them (Tonges &
Ray, 2011, p. 374). Kristin Swanson, a registered nurse, earned her PhD from the University of
Colorado. She developed her Theory of Caring after doing work with patients who had
experienced a pregnancy loss. Swansons Theory of Caring focuses on the nurse delivering
nurturing care based upon her own system of values and knowledge base (Swanson, 2009).
Swansons Theory of Caring is integral in the development of important professional
practice models that are utilized nationwide; examples include the Carolina Care Model (Tonges
& Ray, 2011) and Relationship-Based Care (Creative Healthcare Management, 2014).
Professional practice models are implemented to assist institutions in achieving goals for
performance. Relationship-Based Care is a professional practice model that incorporates six
basic components: teamwork, leadership, patient-care delivery system, outcomes management,
resource-driven practice, and professional nursing practice (Shellner, 2007). These outcomes are
highly desirable in todays healthcare environment. They implement change at the cultural level
and focus on core values; changes needed to address the requirements brought forth by the
changes in the focus of healthcare. Swansons Theory of Caring is an integral part of
Relationship-Based Care model (Creative Healthcare Management, 2014).

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Research-Based Justification of Shared Governance
Qualitative Benefits
Several studies show correlation between SG implementation and one or more of the
following qualities: intent to stay, empowerment, lowered turnover rates, and increased
measures of positive practice environment.
Studies measuring anticipated turnover rate among critical-care (Hauck, Quinn Griffin, &
2011) and behavioral health nurses (Smith, Capitulo, Quinn Griffin, & Fitzpatrick, 2012) show
significant correlation between reports of empowerment and a lowered anticipated turnover rate.
One study examining job satisfaction and turnover rate after revision of a clinical ladder program
with SG, showed high levels of job satisfaction and low levels of turnover after implementation
(Winslow, Knight, Rossen, Fickley, Richards & Rumbley, 2011). There is also been shown to
be a correlation between organizations with Magnet

certification and positive nurse practice

environment (Clavelle, Porter-OGrady & Drenkard, 2013).
Financial Benefits
There is a distinct lack of research showing, quantitatively, the direct financial benefits
related to implementation of shared governance. Assumptions can be made that costs from
increased turnover rates, factors related to lower performance on quality and safety issues, and
reduced reimbursement from insurance companies and the Centers for Medicare and Medicaid
Services (CMS) would be positively affected by a strong and well-run system of SG, however,
the assumption that the associated costs of implementing and maintaining SG are lower than the
savings generated are not as clear.
Specific tools for assessing the financial effect of SG are discussed in the article
Quantifying the Benefits of Staff Participation in Shared Governance (2013) and may be used to
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understand the nature of quantification of benefit. These tools are: return on investment, cost
avoidance, and cost-benefit analysis (Rundquist & Givens, 2013). Comprehensive research in
this area, however, is lacking.
Inferences and Implications
After examination of the selected history leading up to the development and utilization of
SG in the profession of nursing, it is inferred that it was the management model most suited to
the increasing demands of the healthcare environment; however, other options or models were
not analyzed for this paper. It is also inferred, after examination of research inquiring into the
relationship between SG implementation and its effects on nurse work environment, nurse
retention, and job satisfaction, that this relationship has been positive. No implications can be
made regarding the effect of implementation of SG on the financial health of organizations.
More examination is needed for research routes that were not presented here.
Recommendations for Quality and Safety
Quality and Safety Education for Nurses (QSEN)
The QSEN Institute has developed six competencies to be demonstrated by nursing
students in two categories: pre-licensure and graduate level. Subcategories entitled Knowledge,
Skills, and Attitudes provide clarification of the content to be developed (QSEN Institute, 2014).
For the purposes of this paper, pre-licensure competencies only will be discussed.
The goal of the QSEN Competency entitled Teamwork and Collaboration is to
[f]unction effectively within nursing and inter-professional teams, fostering open
communication, mutual respect, and shared decision-making to achieve quality patient care
(QSEN Institute, 2014). Skills in this area are critically important for the nurse to develop
proficiency in; however, they may not be mastered for years after the nurse has been in practice,
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without the guidance of knowledgeable and supportive educators and leadership. The
demanding healthcare environment of today requires skilled and professional collaboration with
many disciplines from within, and also from outside, the employing institution.
Recommendations regarding this competency include: supportive introduction to the
concepts and opportunities for exploration during the early, pre-licensure educational time
period, perhaps as in an ADN program. Emphasis should be made on the acknowledgement that
mastery will not occur without practice and experience. Later in the educational period, perhaps
during the acquisition of a Bachelor Science in Nursing degree, further exploration and
supportive guidance should be given by instructors, allowing the new nurse or nursing student to
develop these skills along with the confidence necessary to collaborate effectively in the role of
patient advocate.
American Nurses Association (ANA) Scope and Standards of Practice
Education, resources, and opportunities for growth with respect to the following ANAs
Nursing: Scope and Standards of Practice should be sought out by nurses and supported by
nurse leaders (Johns, n.d.):
Standard 11: Communication (ANA, 2010)
Communication-skills education and opportunities to practice with any and all
interdisciplinary teams should be strongly supported and facilitated (Johns, n.d.).
Standard 12: Leadership (ANA, 2010)
As a leadership activity, participation in shared governance should be strongly
supported and encouraged (Johns, n.d.).
Standard 13: Collaboration (ANA, 2010)
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Professional inter- and intra-disciplinary collaboration is a foundation of healthcare.
Growth opportunities in this area should be sought out by nurses and supported by
leadership(Johns, n.d.).
Conclusion
There is predicted to be a serious nursing shortage by the year 2020. The reasons for this
shortage are multifactorial but include nurses leaving the workforce due to the nurse increased
stress of the work environment, and an increase in demand for nurses due to the nations aging
population. The Nurse Reinvestment Act of 2002 and publications that refocused the nature of
healthcare have contributed to the changing healthcare and nurse work environment. Strategies
to deal with the predicted nursing shortage and to address changes in the healthcare environment
have included widespread implementation of new professional practice models which are based
upon sociologic, business, and nursing theory. Shared governance is a major component of
many of these professional practice models. The Magnet

Certification Program resulted from

studies of effective nurse work environments and incorporates shared governance. Research
was done to ascertain the effectiveness of programs of which shared governance is a major
component. Evidence shows that while the nurse practice environment and nurse retention rates
have been positively affected by these practice models, financial justification is not well-studied.
Recommendations for improvements in quality and safety within the entities of QSEN and the
ANAs Scope and Standards of Practice were posed, which include educational and leadership
support of the QSEN competency Teamwork and Collaboration, and for ANA Standards 11-
Communcation, Standard 12-Leadership, and Standard 13-Collaboration.
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References
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