JONA
Volume 46, Number 6, pp 308-312
Copyright B 2016 Wolters Kluwer Health, Inc. All rights reserved.
THEJOURNALOFNURSINGADMINISTRATION
Evolution of Structural Empowerment
Moving From Shared to Professional Governance
Joanne T. Clavelle, DNP, RN, NEA-BC, FACHE
Tim Porter O_Grady, DM, EdD, APRN, NEA-BC, FAAN
OBJECTIVE: The aim of this study is to describe the
maturation of the concept of shared governance to
professional governance as a framework for struc-
tural empowerment.
BACKGROUND: An analysis of the literature and
concept clarification of structural empowerment and
shared governance demonstrate that the concept and
attributes of shared governance have evolved toward
professional governance.
METHODS: A comprehensive, deductive literature
review and concept clarification of structural em-
powerment, shared governance, and related con-
structs was completed.
RESULTS: The concept and practice of shared gover-
nance has matured to a concept of professional
governance with the attributes of accountability, pro-
fessional obligation, collateral relationships, and
effective decision-making.
For over 40 years, shared governance (SG) has served
as a nonhierarchical structural framework within
healthcare organizations to create an environment that
supports professional nursing practice and
1,2
interdependence with management. The structure of
SG supported the profession of nursing in estab-
Author Affiliations: Regional Vice President/Chief Nursing
OfficerYWest (Dr Clavelle), GetWellNetwork, Bethesda, Maryland;
Senior Partner (Dr Porter-O_Grady), Tim Porter-O_Grady
Associates, Atlanta, Georgia, Professor of Practice, Arizona State
University College of Nursing and Health Innovation, Phoenix, and
The Ohio State University College of Nursing, Columbus; Chief
Executive Officer (Dr Weston), American Nurses Association,
Silver Springs, Maryland; Professor (Dr Verran), College of
Nursing, Anschutz Medical Campus, University of Colorado,
Denver.
The authors declare no conflicts of interest. Correspondence: Dr
Clavelle, 7700 Old Georgetown Rd, 4th Fl,
Bethesda, MD 20814-2500 (clavellej@msn.com).
DOI: 10.1097/NNA.0000000000000350
308
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Marla J. Weston, PhD, RN, FAAN
Joyce A. Verran, PhD, RN, FAAN
lishing itself as an independent discipline and
advancing its purposes.3 The term shared gover-
nance implies a distinctive differentiation and bal-
ance of accountability between the profession and
organization in which it practices. Shared gover-nance
is distinguished from other participatory man-agement
or employee work group empowerment approaches
because of its specific emphasis on the profession of
nursing_s control and ownership for decisions and
actions related to practice, quality, com-petence, and
knowledge management.4 Working interdependently
as a partner with organizational leadership, nurse-
owned decisions are integrated with management
decisions to achieve desired and mutually agreed upon
outcomes.1,2
Shared governance enables and supports a
professional practice environment that aligns with the
Magnet model component of structural empow-
A
erment and supports nursing ownership of practice,
engagement, role development, professional devel-
opment, and a positive practice environment.5,6 Struc-
tural empowerment is a conceptual antecedent of SG,
whereby professional staff access to empowerment
structures is enabled through authentic and support-ive
leadership7,8 and positively impacts professional
autonomy, sense of organizational justice, respect, and
trust.9
Nursing is a dynamic and evolving practice that
responds to an ever-changing healthcare environ-ment.
Current healthcare systems demand stronger
partnerships and collaborative foundations with nurs-
ing and the entire care team to deliver integrated,
value-based services across the care continuum. To
accomplish this, professional identity, role account-
ability, and interprofessional interface must evolve.
Interprofessional evolution requires clearer role ac-
countability, clinical performance expectations, and
JONA Vol. 46, No. 6 June 2016
health impact. This demands that the professions more
specifically define their character, relationship, and
distinct contribution as a part of the aggregated
professional community.10 The implementation of
team-based clinical practice models continues to ac-
celerate as the template and foundation for the future
of episodic, population-based, and continuum of care
approaches.11 Consequently, appropriate evolution
and maturation of the nursing profession create the
requisite for a nominal but critical shift from the more
limited delineation of Bshared[ governance to the
more broadly established and recognized charac-
terization of Bprofessional[ governance. This article
presents an evolving concept elucidation and makes
the case for clarifying and modernizing the term SG
to the more broadly recognizable and equitably
grounded term professional governance. Building
upon SG conceptual foundations, professional gov-
ernance is characterized by the attributes of account-
ability, professional obligation, collateral
relationships, and decision making.
Background: Structural Empowerment and SG
Structural empowerment consists of professional
gover-nance structures and processes designed to
create an environment where professional practice
flourishes through the engagement, development, and
enable-ment of nurse accountability in designing and
imple-menting practices to ensure quality outcomes
for patients.6 Structural empowerment recognizes and
is designed around power already present in a role and
allows that power to be fully expressed.12
Professional governance structures are grounded
in a full understanding of the social mandate and role
of professions and their obligation to make a positive
contribution to the lives of individuals and commu-
nities. To enable and sustain professional behaviors, a
structural framework is required that ensures a con-
sistent pattern and set of governance activities that
create the environment within which practice is
possible. Because structure creates the contextual
framework and enables behavior, there is an essential
relationship between the structure, which provides
context for the profession, and the practices, which are
the expression of the profession.
Any professional governance structure must
address the 4 core elements of professional practice:
accountability, partnership, ownership, and equity.13
Accountability is the internal obligation to fulfill the
social mandate of the profession through standards
and practices. Partnership reflects the professional
identity and commitment of an individual to the rights
and obligations of the profession in full compliance
with the legal, ethical, professional, relational, and
JONA Vol. 46, No. 6 June 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
interactional requisites of that membership. Owner-
ship suggests a level of engagement to advocate for
those served, deliver quality in the outcomes pro-
duced, and to improve the standards and practices of
the profession. Equity is engendered in value and col-
lateral communication that is founded on comparable
expectations of acceptability, competence, and perfor-
mance with that of other professions.
Clarity about these 4 elements of professional
practice enabled the creation of governance struc-tures
that separated the powers of the profession and the
powers of management. Shared governance was
introduced over 40 years ago as an approach to
structural empowerment where nurses embody and
operationalize autonomy and control over practice.
Shared governance distinguished between the author-
ity of professional nurses and managers. The powers
associated with the profession are control of the
decisions and actions over nursing practice, nursing
care quality, nursing competence, and the creation,
generation, and management of nursing knowledge
(content accountability). This is in contrast to the role
of managers in a professional organization, which is to
provide context for ensuring a safe environment for
the profession to coordinate, integrate, and facilitate
nursing practice and the delivery of patient care. A SG
structure included those forums, councils, collective
deliberation bodies, and associated pro-cesses where
professionals made decisions at the organizational and
unit service levels to advance the work of the
profession and partner and integrate with the strategies
and goals of the organization of which they are
members.
Methods
Situational, temporal, sociocultural, and disciplinary
perspectives shape the understanding and application of a
concept.14 Because the concept of SG was form-ulated
over 40 years ago, a concept analysis of structural
empowerment and SG was conducted to understand how
the concept has evolved and is in use today. An in-depth
literature review was conducted, culling references
within the last 10 years on CINAHL, Medline, PubMed,
and PsychInfo using the key words shared governance,
shared decision-making, Magnet, profession, and
professional, organization, and rela-tionship, and
structural empowerment (including structure and
empowerment as separate terms). Defining attributes,
antecedents, and outcomes were reviewed, as well as the
relationship of these concepts to one another and
Kanter_s structural theory of power in organizations.
Concept clarification worksheets and matrix tables were
constructed, delineating the definitions, defining
attributes, antecedents, and
309
outcome characteristics. The review was expanded to
include the attributes of collaboration, relationship,
partnerships and teamwork, nursing engagement, em-
powerment, and managing change, professional nurs-
ing practice, accountability, and decision making.
Through in-depth analyses and discussions, the
elements of SG were noted to have evolved over time
to professional governance. Four attributes of pro-
fessional governance were identified as foundational
to autonomous nursing practice and the achievement
of exemplary empirical outcomes: accountability, pro-
fessional obligation, collateral relationships, and de-
cision making. These 4 attributes, and their defining
characteristics, are summarized in Table 1. A cross-
walk between elements of professional practice and
the attributes of the concept of professional gover-
nance illustrates this evolved framework in Table 2.
4 Attributes of Professional
Governance Behaviors
Accountability
Accountability is the assurance that decisions and
actions represent the standards of the profession and
positively impact intended client, staff, and organi-
zational outcomes. Characteristics of accountability
include intentionalityVthe alignment of professional
behaviors with client, nursing, and/or organizational
outcomes; change managementVparticipation in
decisions about change and the evaluation of inno-
vations and changes; speaking outVthe overt reactive,
situational expression of professional obligation; and
advocacyVthe formal demonstrative process to ad-
vocate for the interests of those served.
Professional Obligation
Professional obligation is the professional, ethical, and
legal responsibilities within the professional role that
influence practice within the profession, organi-zation,
and community. The characteristics of pro-fessional
obligation are legalVthose practice principles that are
defined in law; ethicalVpractice principles that are bound
by professional ethics; organizational
engagementVobligations that evidence organizational
commitment; professional involvementVobligations that
relate to professional commitment; knowledge seek-ing
and growthVobligations for lifelong growth and
development; and community engagementVobligations
related to involvement in the wider community.
Collateral Relationships
Collateral relationships are the demonstration, estab-
lishment, and expression of equitable interprofessional
relationships and interactions. Sharing goals and coor-
dinating work through relationships are deeply em-
bedded in professional identities and relational
coordination.15 The characteristics of collateral rela-
tionships include relational coordinationVthe manner

Table 1. The Concept, Attributes, and Characteristics of Professional Governance

Concept Definition
Professional governance The accountability, professional obligation, collateral relationships and decision-making of
a professional, foundational to autonomous practice and achievement of exemplary
empirical outcomes.
Attribute Definition Characteristics

Accountability The assurance that decisions and actions represent the Intentionality
standards of the profession and positively impact Change management
intended client, staff, and organizational outcomes Speaking out
Advocacy
Professional obligation The professional, ethical, and legal responsibilities that Legal
influence practice within the profession, organization, Ethical
and community Organizational engagement
Professional involvement
Knowledge-seeking and growth
Community engagement
Collateral relationships The establishment, expression, and demonstration of Relational coordination
equitable interprofessional relationships and interactions Collective convergence
Decision making The exercise of judgment grounded in the synthesis of Framework
evidence-based data to generate alternatives and make Identifying problems and opportunities
informed choices that drive actions and innovation Enacting the decision
within the profession and organization

310 JONA Vol. 46, No. 6 June 2016

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

 Table 2. Crosswalk of Elements of Professional Practice vs. Attributes of Professional Governance
Elements of Professional Practice
Accountability is the internal obligation to fulfill the social
mandate of the profession through standards and practices.
Partnership is the professional identity and commitment of
an individual to the rights and obligations of the
profession in full compliance with the legal, ethical,
professional, relational, and interactional requisites of that
membership.
Ownership is a level of investment/engagement to
advocate for those served, deliver quality in the outcomes
produced, and to improve the standards and practices
of the profession.
Equity is engendered in value and collateral communication that
is founded on comparable expectations of acceptability,
competence, and performance with that of other professions.
in which disciplines work together to achieve shared
goals; and collective convergenceVthe existence
within work settings of factors required for effective
interdisciplinary work.
Decision Making
Decision making is the exercise of judgment grounded
in the synthesis of evidence-based data to generate
alternatives and make informed choices that drive
actions and innovation within the profession and
organization. Characteristics of decision making
within professional governance include frameworkVa
formal organized governance structure for nurses that
dem-onstrates ownership for decisions related to
practice, quality, competence, and knowledge;
identifying problems and opportunitiesVusing relevant
infor-mation to recognize a problem or opportunity;
and enacting a decisionVdeciding, implementing, and
eval-uating a decision.
Implications for Practice
After 4 decades of constructing and implementing
nursing and interprofessional governance models, it is
now time to transition from the generic term of SG to
the more current, evidence-based concept of pro-
fessional governance in organizations. This shift will
require an in-depth understanding of the unique
characteristics that make up the 4 core attributes of
professional governanceVaccountability, profes-sional
obligation, collateral relationships, and deci-sion
making.
JONA Vol. 46, No. 6 June 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Attributes of Professional Governance
Accountability is the assurance that decisions and actions
represent the standards of the profession and positively impact
intended client, staff, and organizational outcomes.
Professional obligation is the professional, ethical, and
legal responsibilities that influence practice within the
profession, organization, and community.
Collateral relationships is the demonstration, establishment,
and expression of equitable interprofessional relationships and
interactions
Decision making is the exercise of judgment grounded in the
synthesis of evidence-based data to generate alternatives and
make informed choices that drive actions within the
profession and organization.
To make this shift, nurse leaders will want to
intentionally assess the existence of the structural and
cultural elements of professional governance in their
organizations, comparing the foundation for SG they
may currently have in place with the attributes and
characteristics of professional governance behaviors.
Creating a worksite culture that supports professional
governance and supports professional obligation, ac-
countability, and relationships may remove the hazi-
ness that sometimes exists between management and
staff roles and decision making that can be implied by
the word shared. The distinction of professional gover-
nance creates clarity regarding the professional role
within an empowering culture where nurses own and
meet the social responsibilities of their roles, inno-
vate, and transform their practice, and function as
peers in the healthcare system. This emphasis upon
professional governance in organizations is easily
transferable to other professions in addition to nurs-
ing. Furthermore, professional governance recognizes
the team_s collective contributions to care and builds
upon interprofessional duties to one_s profession, one
another, and the community.
Nurse executives retain the distinct responsi-bility
for providing the support, resources, and sys-tems to
evolve practice within their organizations.
Intentionally cultivating the attributes and charac-
teristics of a professional governance framework
within an organization strengthens the nursing practice
environment in a way that aligns with the structural
empowerment model component of the Magnet
Recognition Program , harnessing the potential to
A
311
create the organizational structures and processes
integral to the achievement of exemplary empirical
outcomes.
Conclusion
The complexity of the current healthcare system
demands the full contribution and commitment of
nurses as engaged and aligned members of the team.
Structural empowerment creates the framework for
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JONA Vol. 46, No. 6 June 2016