DISCURSIVE PAPER

Direct care nurses on the shared governance journey towards positive

patient outcomes
Nicole Kneflin, Lucy O’Quinn, Gina Geigle, Brenda Mott, Dawn Nebrig and Jennifer Munafo

Aims and objectives. To describe shared governance in action through the exam-
ple of one paediatric institution’s decision to institute daily chlorhexidine bathing. What does this paper contribute
Background. Shared governance processes are discussed extensively in the litera- to the wider global clinical
ture; however, implementation of the processes can be challenging. Recently community?
nurses at one paediatric hospital were involved in a hospital-wide practice change • A practical example of shared
where the theoretical approach of shared governance was actualised. Several ques- governance collaboration.
tions arose from direct care nurses about unwarranted variations in bathing prac- • A description of the evidence-
tices across settings and whether bathing standardisation could address the recent based practice project supporting
increase in central line-associated bloodstream infections. Shared governance chlorhexidine bathing.
council members identified daily chlorhexidine bathing as a potential intervention
to standardise bathing across the hospital and to decrease infection rates. At this
time, chlorhexidine bathing had been widely adopted in adult hospitals but was
less commonly practiced in paediatric institutions.
Design. This is a position paper describing the use of shared governance to make
a house-wide practice decision and positively impact patient outcomes.
Method. Inquiry Council members conducted a systematic evidence search on
best practices around chlorhexidine bathing. This evidence was used in Practice
Council discussions to standardise house-wide practice. Once consensus was
achieved, council members collaborated with Education Council to ensure under-
standing, competency, and the adoption and sustainment of the practice change.
Conclusions. Patients with central lines are at decreased risk for acquiring a cen-
tral line-associated blood stream infection due, in part, to the change in nursing
practice to include daily chlorhexidine bathing. The shared governance structure
was the vehicle through which this practice was vetted and instituted.
Relevance to clinical practice. This paper provides a real-life example of leverag-
ing shared governance structures and the direct care nurse leaders within the
councils when an organisation faces critical needs in patient care.

Key words: child nursing, clinical guidelines, collaboration, evidence-based

practice, hospitalised child, nursing intervention, nursing practice, paediatrics

Accepted for publication: 6 October 2015

Authors: Nicole Kneflin, BSN, RN, CPN, NPPC Chair, Cincinnati
Children’s Hospital Medical Center, Cincinnati, OH; Lucy
O’Quinn, BSN, RN, CPN, NPIC Chair, Cincinnati Children’s
Hospital Medical Center, Cincinnati, OH; Gina Geigle, BSN, RN,
CPN, NPIC Chair-Elect, Cincinnati Children’s Hospital Medical
Center, Cincinnati, OH; Brenda Mott, BSN, RN, NPIC Chair-
Elect, Cincinnati Children’s Hospital Medical Center, Cincinnati,
OH; Dawn Nebrig, MSW, LISW, Shared Governance Facilitator,
Cincinnati Children’s Hospital Medical Center, Cincinnati, OH;
Jennifer Munafo, MA, Shared Governance Facilitator, Cincinnati
Children’s Hospital Medical Center, Cincinnati, OH, USA
Correspondence: Nicole Kneflin, NPPC Chair, Cincinnati Chil-
dren’s Hospital Medical Center, 3333 Burnet Avenue, MLC
11012, Cincinnati, Ohio 45229, USA. Telephone: (513) 636 6211.
E-mail: nicole.kneflin@cchmc.org

© 2016 John Wiley & Sons Ltd

Journal of Clinical Nursing, 25, 875–882, doi: 10.1111/jocn.13114 875
N Kneflin et al.
Aims
This paper describes shared governance in action through
the example of one paediatric institution’s decision to insti-
tute daily chlorhexidine bathing. Direct care nurses lever-
aged shared governance councils to promote evidence-based
practice, autonomy over practice, and responsibility and
accountability for nursing practice. This paper tells the
story of active participation in nursing practice change with
the ultimate goal of positive patient outcomes.
Background
Nursing-shared governance has been defined as a ‘decen-
tralised approach which gives nurses greater authority and
control over their practice and work environment; engen-
ders a sense of responsibility and accountability; and allows
active participation in the decision-making process. . .’
(O’May & Buchan 1999, p. 281). As Clavelle et al. (2013,
p. 567) describe, nursing empowerment is positively linked
to ‘autonomy, practice, job satisfaction, nurse-physician
relationships, patient care quality’. Rather than being a
structure that is implemented and then complete, shared
governance is a ‘journey’ (Porter-O’Grady 1995, p. 9). A
shared governance structure has been in practice for over
20 years at one multisite, 575-bed paediatric academic
medical centre. Direct care nurses are expected to represent
their practice in decision-making through this structure.
This nursing-shared governance environment is grounded in
two fundamental premises: (1) for the best decision-making
to occur, those directly involved in that area of practice
must be involved in decision-making about that practice
and (2) the majority of decision-making about practice
should be occurring at the point of direct service (Cincin-
nati Children’s Interprofessional Charter, 2014, p. 2).
Recently nurses at this institution were involved in a
hospital-wide practice decision where the structure and con-
cepts of shared governance were used to evaluate evidence,
make a decision, and communicate and educate about that
decision. Through this real-life example, nurses lived the
journey of shared governance. They experienced each com-
ponent from promoting evidence-based practice to realising
the responsibility and accountability of nursing practice,
and ultimately participating in nursing practice change that
led to positive patient outcomes.
Shared governance structure
The Interprofessional-Shared Governance model used at
this institution is designed around three cornerstones of
876
quality care practice, -education and -research. All levels of
shared governance councils include direct care providers,
managers and other professionals with roles that are essen-
tial to have a robust and informed discussion.
Point of care councils
Due to the large number of nursing professionals at this
organisation, (3706 registered nurses; approximately 2700
of whom are direct care nurses), there are four decision-
making levels to enable and encourage the participation
of direct care nurses: Point of Care Councils, Nursing
Cluster Councils, Nursing Profession Divisional Councils
and Patient Care Governance Council (PCGC). The clos-
est and most accessible level of shared governance for
direct care nurses are the interdisciplinary Point of Care
Councils (see Fig. 1). A Point of Care Council is defined
as, ‘an interprofessional group of direct care providers
and managers who practice with a shared patient popula-
tion. The membership of Point of Care Councils repre-
sents the professions who provide care in that practice
environment’ (Cincinnati Children’s Interprofessional
Charter, 2014, p. 14). In most areas, these councils are
chaired or co-chaired by a nurse. Daily decisions start at
Point of Care councils.
Cluster councils
These Point of Care Councils are then clustered into the
next level of shared governance. The second level of coun-
cils, the Nursing Cluster Councils, is made up of the chairs
from the Point of Care Councils in similar care areas. Nurs-
ing Cluster Councils enable nurses to make decisions that
impact practice across similar units. For example, the chairs
of the councils in the paediatric intensive care unit, cardiac
intensive care unit and neonatal intensive care unit (NICU)
all combine to one Critical Care Nursing Cluster which is
tasked with making decisions that impact practice across
the various intensive care units. In addition to a Critical
Care Nursing Cluster, there are Cluster Councils serving
inpatient medical-surgical care, ambulatory care, emergency
and urgent care, home care, peri-operative care, psychiatry
and research nursing.
Divisional councils
Each Nursing Cluster Council is represented on each of the
four Nursing Profession Divisional Councils
 Nursing Profession Practice Council – Ensures nursing
practice results in the delivery of safe, high quality
evidence-based care.
 Nursing Profession Education Council – Provides direc-
tion for nurses’ professional education and development
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, 25, 875–882
Discursive paper
Figure 1 Interprofessional shared governance model. Source: Susan R. Allen, PhD, RN-BC, Dawn Nebrig, MSW, LISW-S, Jennifer K.
Munafo, MA (2014). Cincinnati Children’s interprofessional shared governance model. Cincinnati, OH: Cincinnati Children’s Hospital.
Used with permission.
to ensure delivery of safe, high-quality, evidence-based
care.
 Nursing Profession Inquiry Council – Ensures an
environment of scholarly inquiry to support provision of
safe, high-quality and evidence-based care.
 Nursing Profession Coordinating Council – Sets priori-
ties for shared governance work within professional
nursing councils, ensuring alignment with strategic ini-
tiatives of the organisation and coordination of councils
for optimal outcomes.
Patient Care Governance Council
Just as the Nursing Profession Divisional Councils are
responsible for decisions about nursing practice, each
patient care profession has a similar discipline-specific
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, 25, 875–882
Direct care nurses on the shared governance
shared governance structure that facilitates decision-making
about their professional practice. Nursing is represented
along with all of the other patient care professionals,
including audiology, child life, integrative care, nutrition
therapy, occupational therapy, pharmacy, physical therapy,
recreational therapy, respiratory therapy, social work and
speech pathology, on a PCGC (see Fig. 1). The purpose of
PCGC is to make decisions that affect the patient/care pro-
vider relationship that span across professions and are sys-
tem-wide in scope. In addition to representatives from the
nursing-shared governance structure and the various allied
health-shared governance structures, the Senior Vice Presi-
dent of Patient Services (Chief Nursing Officer), a physi-
cian, a member of Pastoral Care and a patient/family
representative serve on PCGC.
877
N Kneflin et al.
This well-developed shared governance structure pro-
vided the setting and culture for direct care nurses to
embark fully on the shared governance journey. Through
leveraging the robust shared governance structure to its full-
est, nurses demonstrated how promoting evidence-based
practice, maintaining autonomy over practice, recognising
their responsibility and accountability for practice, and
actively participating in nursing practice change positively
impact patient outcomes.
Design
This is a position paper describing the use of shared gover-
nance to make a hospital-wide practice change that posi-
tively impacted patient outcomes and strengthened the
shared governance process.
Method
The leveraging of the shared governance structure to make
a hospital-wide practice change will be described through
the story of one hospital’s decision to institute daily
chlorhexidine gluconate (CHG) bathing (see Fig. 2). Direct
care nurses are empowered to share identified opportunities
for practice improvement through an electronic Shared
Governance referral system. The Nursing Professional
Practice Council (NPPC) leadership team, consisting of the
Chair (a direct care nurse), the Chair-Elect (a direct care
nurse), a Nursing Leadership representative and a Shared
Governance Facilitator, reviews referrals on a monthly
basis. Over a short amount of time, NPPC received a
number of referrals related to bathing practices. The NPPC
members realised that there were two main themes among
the bathing referrals: (1) unwarranted variations in bathing
practices across settings and (2) the incidence of central line
associated blood stream infections (CLABSIs) had been
increasing. One of the referrals proposed CHG bathing as a
possible practice change. At that time, there was extensive
literature supporting CHG bathing among adults in critical
care settings and CHG bathing had been widely adopted in
adult hospitals but was less commonly practiced in paedi-
atric institutions (Sievert et al. 2011, Derde et al. 2012,
Karke & Cheng 2012, O’Horo et al. 2012, American Asso-
ciation of Critical-Care Nurses 2013; Climo et al. 2013).
The NPPC members recognised that daily CHG bathing
was a potential solution to these two referral themes. If
daily CHG bathing was determined to be a reasonable
intervention to decrease CLABSIs, it could be standardised
across the hospital thereby eliminating the unwarranted
practice deviations.
878
Nursing Professional Inquiry Council’s Role
Nursing Professional Practice Council members decided
that they needed an evidence synthesis about CHG bathing
to make an informed evidence-based decision about the
standardisation of bathing practices to include CHG
bathing. Therefore, NPPC sent the CHG bathing referral to
the Nursing Professional Inquiry Council (NPIC) and asked
for an evidence-based recommendation about the use of
CHG for daily bathing in children.
Nursing Professional Inquiry Council collectively formu-
lated the clinical question: Among children with central
lines, does daily bathing with CHG, as compared to daily
bathing with soap and water, affect rates of bloodstream
infections during an inpatient hospital admission? A sub-
group of NPIC members was formed to perform a search
of the evidence. This sub-group searched the electronic
database, PubMed, and used key terms: Chlorhexidine
bathing in children, chlorhexidine bathing and infections,
bathing and children. They appraised, synthesised and
summarised the relevant evidence into a table (National
Guidelines Clearinghouse, 2013). The subteam critically
appraised articles found through the search and compiled
the evidence into a table. The subteam provided the table
and all of the articles to all of the NPIC members. The
NPIC members had a robust discussion around the sam-
ples of the included studies, while there was overwhelm-
ing evidence supporting the efficacy and safety of CHG
bathing in an adult population, council members were
seeking to make a decision for a paediatric institution. At
the time of this discussion, there were two studies that
included paediatric samples (Rupp et al. 2012, Milstone
et al. 2013). One high level study that studied CHG
bathing in a paediatric sample and found that daily
CHG bathing decreased CLABSIs among children in
intensive care units (Milstone et al. 2013) and one study
that included children older than two months of age with
a larger sample of adults and found a decrease in
CLABSI when CHG bathing was implemented (Rupp
et al. 2012).
Through a discussion guided by the evidence table and
focusing on the one paediatric-only study (Milstone et al.
2013), NPIC members reached consensus on evidence-
based recommendations to send to NPPC. Based on the
overwhelming evidence in adult literature and the emerg-
ing evidence in paediatric literature, NPIC members wrote
the following recommendation statement: It is strongly rec-
ommended that patients older than two months of age in
a critical care setting receive a daily bath using CHG to
decrease the risk of blood stream infections. It is recom-
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, 25, 875–882
Discursive paper Direct care nurses on the shared governance

NPPC Leadership NPPC Leadership received

received referrals referral suggesting daily
regarding the need to CHG bathing as a way to
standardize bathing decrease CLABSI rates
practices (January 2013) (March 2013)

NPPC Leadership
forwarded a request to
NPIC to complete an
evidence summary about
CHG bathing

NPIC conducted a
NPIC wrote a Best Evidence
systematic review and
Statement based on the evidence
wrote an evidence
summary and submitted it to
summary about CHG
national guidelines
bathing which was sent to
clearinghouse (July 2013)
NPPC (April – May 2013)

NPPC engaged stakeholders in

discussion – including MDs, infection
control, pediatric experts

(September 2013 – January 2014)

NPPC made decision to

standardize best practice to
include daily CHG baths

(February 2014)

NPEC launched mandatory

Practice change was
education about CHG
rolled out
bathing
(May 2014)
Figure 2 Chlorhexidine gluconate (CHG) (April 2014)
bathing flow diagram.

mended that the NICU Practice Council make its own

decision regarding patients older than two months due to
their unique environment. NPIC sent this formal recom-
mendation letter to NPPC and the Vice President of Safety
at our institution. Finally, while NPIC saw their work as
an important foundation to NPPC’s practice decision at
our institution, members also saw this work as having
potential impact outside of our institution. Therefore, the
evidence-work of NPIC was submitted to National Guide-
line Clearinghouse (National Guidelines Clearinghouse
2013) and published as a guideline to inform practice
more broadly.
Nursing Professional Practice Council’s Role
To decide on practice internally, NPPC used the guideline
submitted to the National Guideline Clearinghouse
(National Guidelines Clearinghouse 2013) as the framework
for the conversation. The discussion included patient appli-
cability, what patients should be excluded from the bathing
practice and clarifications around the evidence presented in
the evidence table (National Guidelines Clearinghouse
2013). NPPC members realised there was only one paedi-
atric-only study upon which to base their decision (Milstone
et al. 2013). While the one study was well-designed and

© 2016 John Wiley & Sons Ltd

Journal of Clinical Nursing, 25, 875–882 879
N Kneflin et al.
showed a positive impact of CHG bathing without serious
adverse events, members sought input from infection control
experts and paediatric experts to seek consensus on the best
decision for a paediatric hospital. The cluster representatives
raised questions and concerns from the points of care they
represented allowing for specific patient population-based
questions to be addressed. NPPC Leadership met with
physicians to seek their feedback and support. Through
these collaborations, CHG bathing became incorporated
into larger division-specific initiatives to decrease hospital-
acquired conditions. After months of crucial conversations,
healthy debates and accessing additional resources, NPPC
came to consensus that a daily CHG bath should be pro-
vided to all patients who meet the following criteria:
 Patients in the critical care setting (PICU (Pediatric
Intensive Care Unit), NICU (Neonatal Intensive Care
Unit), Heart Institute) greater than two months of age,
 Patients outside of the critical care setting greater than
two months of age and have a central line.
 Exclusions to a daily CHG bath include
○ Patients with known allergies to CHG or any other
ingredients in the product,
○ Patients with open/impaired areas, including but not
limited to severe skin disease such as graft vs. host,
or burns,
○ Patients with ulcerated skin areas and pressure ulcers
greater than stage 1,
○ Patients with low birth weight (<1500 g) or prema-
ture infants (earlier than 37 weeks gestation)
○ Patients who have received a lumbar puncture within
the past 24 hours.
The cluster representatives then began to filter informa-
tion about the upcoming practice change to the clusters and
Points of Care that they represented. This allowed direct
care nurses to be aware of upcoming change and to ask
any questions or clarifications as the education and imple-
mentations were being planned.
Nursing professional education council’s role
Once consensus was achieved around the standardisation of
the daily CHG bathing, education needed to be provided to
the direct care nurses to ensure the adoption and sustainment
of the practice change. NPPC collaborated with Nursing Pro-
fessional Educational Council (NPEC) to develop educa-
tional materials for nurses and unlicensed assistive personnel.
The objective of the education was to provide direct care pro-
viders the information necessary to identify the appropriate
patients to receive the CHG bath, with the knowledge needed
880
to perform a CHG bath, and the rationale for the CHG bath-
ing practice change to allow for educated discussions with
patients and families. NPPC Leadership attended an NPEC
meeting to present the CHG bathing materials. NPEC
assigned an Education Consultant to be a resource for NPPC.
NPPC and NPEC collaborated work efforts to ensure staff
were provided with the proper education to deliver safe
patient care. In addition, NPPC Leadership created an educa-
tional handout for staff to use to educate patients and fami-
lies about the CHG bathing practice and procedures.
Families were provided this education about CHG bathing as
a way to empower families to become involved in their
child’s hospital care.
Evaluation
Through detailed planning and involvement of appropriate
stakeholders throughout the decision-making process, the
implementation of the practice change progressed smoothly.
The shared governance councils involved in this decision
and practice change were integral in the evaluation of the
practice change. This evaluation occurred on two levels: (1)
the evaluation of the specific CHG bathing practice change
on patient outcomes and (2) a broader evaluation of the
process used to make a practice decision.
To allow for evaluation of the CHG practice change on
patient outcomes, NPPC collaborated with quality improve-
ment and safety experts and management. There were three
specific measures to evaluate the practice change. The first
two were process measures allowing for evaluation of the
roll-out of the practice change:
 Initial education – CHG bathing education completion
rate
 Practice adoption – The hospital performs monthly pre-
vention standard rounding that includes compliance
audits. The plan for sustainability was for NPPC to part-
ner with the assigned Quality Outcomes Manager to
review the monthly data. Additionally, the council dis-
cussed any barriers or aides that may have attributed to
compliance levels.
The third was an outcome measure allowing for evaluation
of the practice change in impacting patient outcomes:
 CLABSI rates – The incidence of CLABSIs at our insti-
tution dropped following implementation of CHG bath-
ing. There are numerous potential variables that could
have affected the CLABSI rates during this time and
while council members did not feel that the CHG bath-
ing alone decreased CLABSI rates, this practice change
was part of other interventions that together had a
positive impact on patient outcomes.
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, 25, 875–882
Discursive paper
Council members discussed the process and identified an
area for improvement. Council members wanted to
decrease the length of time from receiving the referral until
a house-wide practice change was implemented. It took
approximately 12 months from the time the referrals were
received until a practice change was implemented. The
delay was related to Nursing Divisional Council meetings
occurring monthly and discussions were continued over
multiple meetings. The council identified an opportunity for
a more efficient system that would facilitate practice change
in a timelier manner.
Prior to and during this time period, the chairs of the Nurs-
ing Profession Divisional Councils gathered with cluster
chairs once a month, to coordinate efforts of the referrals
being managed by each Nursing Divisional Council. Each
divisional council acted independently until a referral was
passed to another council. This increased the time for prac-
tice changes to occur because council work was not com-
pleted simultaneously. To address this area of improvement,
a monthly Single Agenda Planning meeting was launched in
July 2014. The intention of this meeting was to allow the
leaders of each council to coordinate efforts and plan for
their specific council’s role in completion of the referral.
Members of this meeting include the chairs, chairs-elect and
their respective Patient Services Leadership member. An
advantage of this monthly meeting with the Divisional chairs
is to coordinate these efforts to allow NPIC and NPPC to
work simultaneously on referrals, while allowing NPEC to
properly plan for upcoming associated education. In addi-
tion, having multiple Patient Services Leadership members
invested in the earliest stages of a referral promotes collabo-
rative work towards removing barriers and making connec-
tions with other institutional entities.
Conclusions
In conclusion, leveraging the shared governance council
structure to make an evidence-based practice decision and
to implement this change was a positive experience. The
council structure allowed for input and discussion among
clinicians of all the nursing clusters. By having stake-
holder input early in the decision, concerns were
addressed early on and the implementation plan met the
needs of each patient population. The work was all con-
ducted during prescheduled shared governance council
meetings using the resources allotted for shared gover-
nance involvement. The largest lesson learned was the
time it took for the work to get completed and transfer
between councils, we have attempted to address that
obstacle by instituting a monthly Single Agenda Planning
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing, 25, 875–882
Direct care nurses on the shared governance
meeting. The approach using the shared governance struc-
ture to evoke practice change could be transferred to
other institutions through the lessons learned in our expe-
rience (Table 1).
The clinical outcome due, in part, to the change in nurs-
ing practice and accompanying education to include daily
CHG bathing, is that patients with central lines at this
organisation are at decreased risk for acquiring CLABSIs. A
shared governance structure was the vehicle through which
this practice was vetted and determined to be best nursing
practice in the organisation. Although there is a clear iden-
tification of the clinical outcome, the shared governance
process of deciding, implementing and evaluating the prac-
tice change also provided council leaders with opportunities
to build their shared leadership competencies of ‘negotiat-
ing win-win solutions, facilitating change, influencing
follower behaviour, thinking and problem solving in a sys-
tem’s framework, empowering others to act responsibly
through shared visioning and facilitating decision-making
through a shared leadership paradigm’ (George et al. 2002,
p. 47). The intention in sharing this experience is to
promote leveraging shared governance structures and the
clinical nurse leaders within the councils when an organisa-
tion faces critical needs in patient care.
Relevance to clinical practice
While many hospitals have adopted shared governance pro-
cesses and structures, implementing those processes and
structures is more challenging. This paper provides a real-life
example of how direct care nurses at one institution lever-
aged shared governance structures and the clinical nurse
leaders within the councils to address an opportunity for
practice change, to make an evidence-based practice deci-
sion, to promote adoption and sustainability of the practice
change and to ultimately improve patient care outcomes at
one institution.
Table 1 Lessons learned
1. Inform chairs about their council’s potential involvement, as
early as possible.
2. Systematically communicate to both inform and update council
chairs on progress.
3. Ensure all key stakeholders are involved in dialogue, decision-
making, implementation and evaluation. This includes shared
decision-making between bedside clinicians and operational
leaders.
4. Identify potential barriers, concerns and mitigation strategies
prior to implementation.
5. Use a practice model to facilitate dialogue and decision-making.
881
N Kneflin et al.

Acknowledgements
Our gratitude to the following people who work every
day to improve care and outcomes for our patients:
NPIC members (FY13-FY14) with special thanks to
Rachel Baker, Sarah Baker, Jackie Gruer, Diane Lemen,
Mary Ellen Meier, Jenny Miller and Heather Tubbs-
Cooley, NPPC members (FY13-FY14), Clare Duane,
Brandy Seger.
Contributions
Study Design: NK, LO, GG, BM, DN, JM; Data Collection
and Analysis: NK, LO, GG, BM, DN, JM; Manuscript Pre-
paration: NK, LO, GG, BM, DN, JM.
Conflict of interest
The authors declare that they have no conflict of interests.

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© 2016 John Wiley & Sons Ltd

882 Journal of Clinical Nursing, 25, 875–882