Shared Governance

Nursing Department

October 2021
Introduction
• Nurses constitute the largest group of health care workers in the health services
domain. It is just logic to assume that if nurses are fully engaged, satisfied and
supported and have some control over the work that they produce, health service
organizations have a better change to provide relevant health care that add value to
the clients and communities they serve.
• The principle idea of shared governance is that decision making and the use of
power should happen at the right place, this translate that staff nurses and nurse
leaders work together to develop nursing practice and staff nurses have the
opportunity to control their own practice, Kanninen, et al 2019.
Structure – Facilities
Structure – EHS Corporate
Terms of Reference – Executive Nursing Committee (Facilities)
Purpose: To provide leadership, support and governance to ensure the Meetings:
nursing committees are successful and reach their goals. • The Nursing Executive Committee will meet monthly for
Scope: Professional Practice Model one hour.

Reporting: Executive Nursing Committee • A minimum of 10 meetings per year will be scheduled.
• Members must attend at least 75% of yearly meetings
Responsibilities:
• Membership and Terms of Reference will be reviewed
• Is responsible to assign the 4 committees’ members.
annually.
• Ensure that the committee members are trained to take up the work
of the committee. Members
• Provide guidance to all the committees.
• Evaluate the work and outcomes of the committees by reviewing
all the KPIs from each committee.
• Provide feedback to the Hospital Executive Team to all matter
relating to nursing services.
Terms of Reference – Nursing Operations Committee (Facilities)
Purpose: To provide leadership and governance to ensure the Responsibilities
implementation of Professional Practice Model as it relates to Workforce • Develop, set, review and report on nursing
Planning, Strategic Plans/ Business Plans Nursing, Budgets, Operational workforce performance and planning goals and
and process related issues, Informatics, Quality Improvement.
outcomes at least every 6 months.
Scope: Workforce Planning, Strategic Plans/ Business Plans Nursing,
• Set major goals in alignment with the strategic
Budgets, Professional Practice Model, Operational issues and process
and operational plans of ESE nursing services by
related to Nursing, Informatics, Quality Improvement.
using a systematic approach.
Reporting: Executive Nursing Committee.
• Provide guidance on all nursing workforce
Meetings:
planning and recruitment matters.
• The Nursing Operations Committee will meet monthly for one hour.
• A minimum of 10 meetings per year will be scheduled.
• Assist in the development, implementation and

• Members must attend at least 75% of yearly meetings monitoring of the strategic plan for the hospital.
• Membership and Terms of Reference will be reviewed annually.
 Terms of Reference – Nursing Operations Committee (Facilities)
Responsibilities (Continuation)
• Monitor the implementation of the Professional Practice
Model.
• Improve communication, cooperation, collaboration and
engagement between all nurses and nursing
departments.
• Develop a shared approach to staff management,
teamwork, engagement and satisfaction.
• Inform, advice on all operational issues to ensure the
most efficient and effective management of all nursing
processes, procedures and activities
• Ensure that all relevant data are available to manage
• Develop, set, review and report on performance goals and
outcomes at least every 6 months. Through setting major
goals in alignment with the strategic and operational plans of
---- nursing services including oversight of nursing and
clinical KPI performance and monitoring unit-based quality
improvement plans.
• Establish and review operational policies and guidelines to
ensure maximum efficiency and effectiveness.
• Ensure ---- Hospital is complying with all Pathways to
Excellence standards in order to create a positive work
environment for nursing employees and to achieve the
Pathway to Excellence designation.
Terms of Reference – Nursing Operations Committee (Facilities)
Members
 Terms of Reference – Evidenced Informed Committee (Facilities)
Purpose: To provide leadership and governance to the Nursing Responsibilities:
• Establish and review clinical practice policies and guidelines to
Executive Committee to ensure nursing practice activities meet
ensure compliance with contemporary Evidenced Informed practice
or exceed international standards. To monitor, guide and inform
• Respond to advice/concerns from Nursing Executive Committee.
the Executive Committee regarding best practices and to
• Increase awareness of nurses on research, EIP projects and foster an
promote the use of evidence Informed practice in ------- Hospital. environment conducive to the advancement and utilization of nursing
Scope: Ensure nursing practice is evidenced informed, review research in collaboration with the Clinical Research Ethics
all educational content provided to Registered Nurses, support/ Committee.

encourage research, develop/ review all clinical policies, practice• Review, prioritize ----- nursing research activities, support and assist
the staff in undertaking and presenting research/EBP
guidelines and ensure evidenced informed.
project/Abstracts/Posters.
Reporting: Executive Nursing Committee
• Develop, set, review and report on performance goals and outcomes
at least every 6 months.
• Develop/review all hospital based educational content provided to
 Terms of Reference – Evidenced Informed Committee (Facilities)
Meetings:
• The Evidenced Informed Committee will meet
monthly for one hour.
• A minimum of 10 meetings per year will be
scheduled.
• Members must attend at least 75% of yearly
meetings
 Terms of Reference – Wellbeing Committee(Facilities)
Purpose: To provide leadership and governance to improve the Responsibilities: (Continuation)
retention and engagement of nurses at ----- Hospital, create a • Implement nursing recognition and professional

positive work culture and introduce community projects. development systems such as the clinical ladder program.

Scope: Staff support activities, Nurses day or other proposed • Organize hospital nursing events celebration on an annual

celebration, support during Ramadan, HR related issues, basis such as nurse’s days, end of year celebration, etc.

recognition programs. • Analyze and action staff satisfaction surveys undertaken.

• Identify, initiate and support staff undertaking community
Reporting: Executive Nursing Committee
outreach programs.
Responsibilities:
• Respond to advice/concerns from Nursing Executive
Committee.
• Assist in identifying, assessing, implementing, and evaluating
retention and engagement activities for the nursing employees
Terms of Reference – Wellbeing Committee(Facilities)
Meetings: Members
• The Wellbeing Committee will meet monthly for
one hour.
• A minimum of 10 meetings per year will be
scheduled.
• Members must attend at least 75% of yearly
meetings
 Terms of Reference – Professional Development
Committee(Facilities)
Purpose : To provide leadership and governance ensure Responsibilities:
nursing practice activities meet or exceed international • Develop, monitor and implement a Training Needs Analysis
standards. To monitor, guide and inform on the that meets nurses professional development needs.
implementation of the Professional Development Model • Monitor compliance to all the modules of the Professional
through collaboration with other disciplines and Development Model.
departments to promote world class professional • Review and oversight nursing KPI’s relating to Professional
development practices in EHS. Development Model.
Scope: Student guidance, oversee and evaluate • Establish and review clinical practice policies and guidelines

implementation of Nursing and Midwifery Professional to ensure compliance with contemporary EIP.

Development Model. • Respond to advice/concerns from Nursing Executive

Reporting: Executive Nursing Committee Committee.

 Terms of Reference – Professional Development
Committee(Facilities)
Responsibilities : Meetings:
• Increase awareness of nurses on research, EIP projects and foster an • The Professional Development Committee will
environment conducive to the advancement and utilization of meet monthly for one hour.
nursing research in collaboration with the Clinical Research Ethics • A minimum of 10 meetings per year will be
Committee. scheduled.
• Mentorship of nurses as they promote/advance within the hospital • Members must attend at least 75% of yearly
and provide support and development of nurse mentoring program meetings
within the hospital including Emiratization.
• Develop, set, review and report on performance goals and outcomes
at least every 6 months.
• Address activities and initiatives related to nursing students and
enhance the image of nursing by engaging the school graduates in
Terms of Reference – Professional Development Committee
(Facilities)
Members
Mandate
• Executive Nursing Advisory Committee is an advisory
and oversight committee, that have 4 Corporate Advisory
Committees; one for
 Nursing Operations Committee
 Evidence Based Committee
 Wellbeing Committee
 Professional Development Committee.
• One Executive Sponsor from EHS will be assigned to each
committee and each of the facilities will send one member
of Shared Governance Committee (facility level) from
Nursing Operations Committee, Evidence Based
Committee, Wellbeing Committee, Professional
Development Committee to the relevant Corporate Advisory
Reporting Structure
• Corporate Nursing Advisory Committees
Meet every 3 months and provide feedback on
the activities of the individual committees and
review KPIs. The Corporate Nursing Advisory
Committee approve or request revisions as
appropriate.
The Corporate Nursing Advisory Committee
will provide guidance and support as required to
all
• the committees.
Executive Nursing Advisory Committees
Executive Sponsor, EHS for each of the
Executive Nursing Advisory Committees will
meet every 3 months with CNO Corporate to
provide progress report to the CNO on the
implementation, challenges, successes of the
Shared Governance Model.
 Chief Nursing Officer

Approval/Acknowledgement

Executive Nursing Advisory Committee Corporate

All hospital/PHC represented. Facilitated by sponsor from EHS.

All ideas policies, etc, reviewed and agreed by all.

Nursing Executive Committee Facility

Facilitate, ensure evidence informed decisions based on international standards, inline with EHS Nursing Department directions.
One members of each 4 committees send to CAC.

Clinical Nurses to be part of decision regarding practice

Implementation Plan
Once the Governance Model is approved in principle by the CNO the following actions will take
place;
1. Expert group of Nurses leaders will meet to review, discuss, revised if needed and approve the
Shared Governance Model (Gail Smith, Margaretha Hayton, Elizabet Leonard, Saleema
Mubarak, Mouza AlShehi, Asma Mazrouie, Shaikha Akran, Fatma Almandoos, Huda Salem)
2. October 2021, Shared Governance will be presented to ADNAs.
3. Magnet Coordinators will be assigned to all facilities.
4. Members for each Committees will be assigned and approved in all facilities.
5. Shared Governance Model has to be activate January 2022.
Appendix