SHARED
GOVERNANCE
Giving nurses a voice in their practice
The System of Care: CareTouch
Peer Feedback
Standardized
Documentation
Core Values
Care Teams
Enhanced
Communication
Patient-Family
Centered Care
Capability
Building
2
Skill Building
Talent
Management
Leader Development
Healthy
Work
Environments
EvidenceBased
Optimized Performance
Shared Accountability
Clinical Inquiry Centers
WHAT IS SHARED GOVERNANCE?
▪ Shared Governance gives nursing team members a voice in
their practice and the innovation of that practice through
elected nursing practice councils at unit, facility, region, and
ANC levels
–Shared Governance:
▫ Creates a structure to implement practice guidelines
▫ Provides a framework for professional accountability
▫ Recognizes staff nurse's authority and responsibility for their practice
▫ Promotes nurses’ voices in their practice
▫ Improves functioning: Substantial literature and experience indicates
that Shared Governance
- Increases nurse engagement
- Improves the working environment
- Improves the quality of care provided
What is Shared Governance?
Shared governance means that as nursing staff, you are
given
▪
A mechanism for implementing practice guidelines on your
unit
▪
▪
A voice in innovating your practice
▪
An easy pathway for sharing concerns and ideas with
management
Representation for bedside nurses at the executive level of
the Department of Nursing
▪ Accountability for all issues elating to nursing practice
▪ Empowerment to translate ideas into actions
How do we achieve it?
Your unit will form a Unit Practice Council (UPC), which will
include:
▪
Members representative of the unit (all positions, active duty and
civilian)
▪
▪
An election based on individuals who self-nominate for the UPC
A UPC Chair, Co-Chair, Secretary, and Facility Nursing Practice
Council rep
GOALS OF SHARED GOVERNANCE

Shared Governance provides a framework for encouraging
professional accountability
Goals
▪
Implement practice innovations,
including clinical practice
guidelines and “quick wins”
supported by peer-reviewed
literature and other evidence
▪ Increase nurse autonomy by
giving nursing team members a
voice in their daily practice and
the innovation of that practice
 Drive and tailor ANSOC
implementation, sustainment,
and refinement on the unit
Impact
Evidence-based practice
innovation, nurse autonomy,
and successful ANSOC
implementation that is
relevant and appropriate for
the unit
BENEFITS OF SHARED GOVERNANCE
Benefits to
unit staff
Benefits to
facility
▪ Allows innovations to get visibility and support from facility-level
▪
▪
leadership
Shares ideas across units
Helps leadership identify when unit struggles actually have a
system-wide basis, and helps proactively address these
▪ Results in significant improvement in nurse engagement
▪
▪
▪
▪
– Increases satisfaction with the work environment
– Improves nurse perception of autonomy
Results in lower nurse turnover (documented rates of <10%)
Decreases nurse absenteeism (documented rates of 0-5%)
A part of achieving Magnet status; part of Pathways to
Excellence
Widely adopted among top nursing practices and best-in-class
healthcare facilities
Benefits described by peer-reviewed
literature listed in the Appendix
HOW THE UPC AND CNOIC/NCOIC WILL
WORK TOGETHER
– CNOIC/NCOIC will turn to UPC as “decider” on key practicerelated issues within their primary scope
– CNOIC.NCOIC will “concur” or in rare cases, veto (see slide 10)
– UPC will need guidance from CNOIC/NCOIC for both practicerelated issues and ANSOC implementation:
▫ Practice-related issues: UPC will want input on quick wins
and practice innovations, including ideas for both, feasibility,
priority and required next steps
▫ ANSOC implementation: UPC will need consultation on
tailoring of ANSOC components
ACCOUNTABILITIES FOR SHARED DECISION-MAKING
Clinical Practice Accountabilities
• Standards of Practice
• Specialty and related
• Clinical competency
• Care Delivery Model
Shared
• Professional Development
Decision• Orientation
Making
• Continuing education
• Certification
• Advanced degrees
• Quality
• EBNP
• Research
• Outcomes
• Peer Review
• Interdisciplinary Relationships
Management Accountabilities
• Resources/Allocation
• Human
• Fiscal
• Material
• Structure
• System/Organizational
Links
• Reward and Recognition
(from continual
performance evaluation)
EXAMPLES OF HOW OTHER UNITS HAVE
IMPLEMENTED SHARED GOVERNANCE (1 OF 3)
Preventing infection
Streamlining a procedure
Setting a name tag trend
▪ An Inpatient Med/Surg UPC
▪ Combined surgical suite UPC
▪ Another inpatient Med/Surg
identified several issues with
wearing ACUs on the floor:
– The long sleeves had
significant potential to act
as a vector for germs
– The need to wash the ACUs
daily was quickly wearing
them out, and they were
expensive to replace
▪ The UPC’s proposal to their
CNOIC recommended the use
of short-sleeve scrubs for
military nurses and provided
evidence that the proposed
change would both reduce the
chance of spreading infections
and the cost of uniforms
▪ Due to the UPC’s evidencebased recommendation, the
uniform was changed to
optional scrubs for all nurses
on the unit
brought voices of nurses from
separate but highly
interlinked groups together
for the first time
▪ Suggestion from OR nurses
requested that the pre-op
nurses put on a specific type
of immobilization before
anesthesia
▪ The UPC immediately worked
to ensure that pre-op nurses
could change a simple
procedure to make OR nurses’
jobs easier
UPC heard that patients were
confused about the roles of
the various nursing team
members
▪ The UPC proposed an
initiative to have name tags
with nurse roles on them
▪ The tags were a hit and
spread to the doctors in the
unit, and from there were
adopted around the facility
because of their popularity
EXAMPLES OF HOW OTHER UNITS HAVE
IMPLEMENTED SHARED GOVERNANCE (2 OF 3)
Hand hygiene
▪ The nursing team of an adult
▪
▪
▪
▪
medicine clinic noticed that
patients did not wash their
hands frequently when at the
hospital
The UPC brainstormed ways to
effectively increase hand
hygiene
The UPC proposed mounting
Purell dispensers in the
hallways to encourage everyone
to have better hand hygiene
The UPC’s recommendation is
in line with evidence on
infection control and frequency
of use with different kinds of
hand hygiene
The CNOIC accepted the
proposal and dispensers were
mounted on the walls
Streamlining a procedure
▪ A Hem/Onc clinic and an inpatient
▪
▪
▪
▪
unit wanted to optimize their
coordination of care
They identified three areas to
improve: communicating more
often, communicating more
effectively, and becoming more
familiar with the other unit’s
operations
The clinic staff began providing a
patients’ last lab, pharmacy flow
sheets, and oncologist note to the
inpatient nursing team
The inpatient unit’s Lead RNs
began calling down to the
Hem/Onc clinic to speak with their
patient’s team to ensure that the
inpatient plan of care was
congruent with the outpatient plan
of care
The UPCs invited each other to
various events (e.g., BBQ, “after
hours” event) to increase
collegiality between the units
Surgical tours
▪ An OR unit and a PACU
▪
▪
▪
realized that patients and their
families got very anxious before
a surgery
To reduce their patients’
anxiety, the UPCs collaborated
to hold a monthly surgery tour
where the patients and their
families could get familiar with
the rooms and what would
happen during care
This allowed patients and their
families to better plan for the
surgery and recovery; it also
laid the groundwork for a
culture of trust and
communication between the
patients, families, and staff
The concept was so successful
and popular that the PAO did
an article on the concept
EXAMPLES OF HOW OTHER UNITS HAVE
IMPLEMENTED SHARED GOVERNANCE (3 OF 3)
Fall prevention
▪ Two inpatient med/surg units
wanted to prevent falls
▪ Their UPCs decided to have a
▪
▪
▪
▪
competition for who could go
longer without any falls
The units put up posters
indicating the number of days
since their last fall
Each reviewed best practices on
falls prevention and instituted
the methods they felt would help
their unit most
Falls decreased dramatically
over the months of the
competition and stayed low
The staff became actively and
creatively engaged in preventing
falls through friendly
competition
Streamlining a procedure
▪ A GI unit and PACU at a
▪
▪
▪
MEDCEN wanted to optimize their
coordination of care
The units had a good record of
communication and wanted to
ensure this trend continued
The units modified an existing
documentation form to accurately
reflect changes in their practice,
familiarized staff through inservices, and monitored compliance
through chart audits
In addition, the units set three
goals:
– GI staff would perform
accurate and complete bed
side hand-off communication
to PACU staff
– PACU discharge criteria
would be met prior to
initiation of report call to the
GI unit
– PACU staff would call report
to a licensed GI staff member
prior to release from PACU
Minimizing need for ABGs
▪ The adult critical care and
▪
▪
▪
respiratory care units identified
that new clinical guidelines called
for use of PetCO2 (capnography)
in several new patient
populations
The nursing staff developed a
recommendation to routinely use
PetCO2 monitoring on patients
receiving moderate sedation and
those at risk for respiratory
compromise, in addition to
intubated patients (who already
were routinely monitored with
PetCO2)
The nursing staff engaged their
leadership, CNS, providers, and
respiratory therapists to properly
implement the change and track
its impact (e.g., reduction in
ABGs)
They instituted hands-on
training with a goal of making
PetCO2 monitoring part of their
daily best practice
ESTABLISHING REPRESENTATIVE UPCS
▪
Guidelines
▪
▪
▪
Representation
– The ratio of nursing roles on the UPC should mimic that of the unit (i.e., % of RNs, LPNs,
CNAs, civilian, and military staff on UPC is reflective of mix on the unit)
– Each member has a constituency they talk to before each meeting and update after
– Constituencies may be assigned, based on who elected them, or based on another model
Nomination
– Individuals can self-nominate or be nominated by others
– In small units, everyone may be on the ballot automatically unless they opt out
Size
– Ideal size of UPC is 5-15 members; each member should have ~4-7 constituents
– Some units may combine to form a council
Terms
– UPC members serve 1-2 years before re-election
Lessons Learned
– Members in good standing can be reelected
▪ Representatives must be able to update all
– Members roll on and off at different times for
their constituents personally – therefore
continuity and institutional memory
representatives should have no more than
– Limiting number of consecutive terms to two
seven constituents
can help most of the staff to serve over the
▪
At Tripler, some UPCs decided all elections
years, facilitating buy-in
would be in January of every year; what
– Election rhythm:
they found was that the new UPC was all
▫ If a UPC decides on 1 year terms, half the
new members and no one knew how to run
positions are up for re-election every 6 months
the meeting or what had been done before.
▫ If a UPC decides on 2 year terms, half the
When they staggered elections, new
positions are up for re-election every 12
members learned from their predecessors
months
QUICK WINS
Quick wins should be…
For each quick win, identify…
▪
▪
▪
The goal/proposal
▪
Data supporting that the goal is a
good one
▪
Data suggesting that this is the
appropriate method to address the
goal
▪
Steps required to get to that goal
▪
▪
▪
▪
Something everyone can get excited
about
Concrete, easy to put your hands on
Rapidly accomplishable
Non-controversial
Able to make a daily difference
Recommendation
Focus on only 1-2
quick wins at a time
The rationale and reasons for the
goal
– Who you need to win over
– What information you need to
collect
▪
Possible challenges and ways to
address those challenges
▪
▪
▪
Backup option/goal
Leader(s) who will own the proposal
Resources the leader(s) can use
UPC COLLABORATION WITH OTHER
GROUPS
▪
The UPC works with other people and groups at both the unit and facility levels
– CNOIC/NCOIC: The UPC identifies and prioritizes quick wins and long term goals and
ANSOC tailoring in conjunction with the CNOIC/NCOIC
– Unit nursing team: A “project board” and/or website are updated every meeting and track
outcomes of UPC projects for all to see
– Guests: The UPC invites guests to sit in on meetings as relevant for problem solving, e.g.,
pharmacy, hospital services
– Facility NPC:
▫ UPCs each elect a representative to the Facility NPC
▫ UPCs present updates and innovations to Facility NPC monthly
▪
Autonomy of the UPC
– Each UPC is self-governing, e.g., deciding for itself how it will conduct meetings and breaks,
schedule rooms, develop norms under its charter etc
– UPCs must still work within unit norms and with the CNOIC/NCOIC
Guidelines
Lessons Learned
Some CNOIC/NCOICs were concerned that they might
not know what changes were happening in the unit or
be able to share key insights, so the Facility NPC
developed a set of guidelines for all UPCs to ensure
that CNOIC/NCOICs kept informed of progress and
had clear channels for providing input and feedback
: EXPECTATIONS FOR UPC ATTENDANCE
AND ROLES
Guidelines
▪ Attendance
– Each UPC representative is required to attend each meeting. Staff are not scheduled
on the floor during meetings. Missing meetings requires an official excuse (must have
annual, military, or sick leave)
– The charter should specify how to deal with members who miss meetings repeatedly
▪ Roles
– There is a Chair, Co-chair and a Secretary
▫ The Chair, Co-chair and Coach solidify the agendas and meet with the
CNOIC/NCOIC before each meeting
▫ The Secretary takes and publically posts minutes and keeps the UPC on track for
due-outs
– These roles are decided at the first meeting
Lessons Learned
One facility found that if all their UPCs met on a
single day each month, it was easier to predict,
schedule for, and reserve rooms. Attendance was
boosted by holding all the meetings on one day;
For other facilities, covering the ward with so
many nurses out or finding rooms for all UPCs
may be hard
RESOURCING UPCS
Guidelines
▪ Time:
– Dedicated time for introducing nursing team to UPC and training those
▪
involved with the UPC
– Dedicated time for members to attend meetings
▫ Early in the process: In order to get traction against the issues required for
the first months UPCs will likely need to meet for 2 hours once or twice
weekly
▫ Steady state: UPCs will meet for ~1 hour monthly1
▫ Members should not be pulled away during meetings
– Dedicated time for Coaches to prepare for meetings, attend and coach
– Dedicated time for Unit Shared Governance Leader/UPC Chair for training
and pushing forward initiatives
Materials:
Lessons Learned
– UPCs need access to:
One facility found that using a meeting space
in a different part of the facility, away from the
▫ Bulletin board
unit, increased the efficiency of meetings
▫ Room for meetings
because it reduced distractions and the number
▫ Other materials, e.g.:
of times the UPC members were interrupted
- Email
with issues on the floor
- Poster supplies
- Access to AKO
1 Some UPCs may meet 2 hours per month or arrange time in other fashions
WILL THE UPC BE REQUIRED TO MAKE TOUGH
DECISIONS?
▪ Unit members will bring issues and recommended
solutions to their UPC
▪ The UPC will not make decisions in a vacuum – they will
receive input and guidance from unit leaders, the
Facility NPC, and others as appropriate
▪ The UPC will develop evidence-based
recommendations/proposals to give to unit leadership
and staff
▪ Everyone will be a part of the decision making process
HOW WILL MY VOICE BE HEARD IF I’M NOT ON
THE UPC?
▪ Every staff member on your unit will be assigned a
member of the UPC as their rep (most UPC members
will be the rep for 4-6 constituents)
▪ Each UPC member is responsible for keeping their
constituents updated on the issues being discussed by
the UPC and getting their feedback
▪ UPC members should have face-to-face contact with
their constituents before and after each meeting
WHAT’S THE DECISION-MAKING PROCESS FOR
THE UPC?
▪ The UPC will decide how it makes decisions and
recommendations – either through consensus or voting
or both
▪ When making decisions, each UPC member will provide
their recommendation based on the input of their
constituents
▪ Additionally, the UPC will take into account any
guidance unit leadership may have provided
▪ Do not take it personally if your recommendation is not
the final outcome –everyone has the opportunity to let
their voices be heard, and the UPC will make the
decision they believe is best for the entire unit
▪ The UPC also has the ability to try a course of action,
then go back to re-evaluate and change directions based
on results and continued feedback
WILL THE UPC WILL COME UP WITH IDEAS
THAT WILL CHANGE LONG TIME ROUTINES?
▪ The short answer is “Yes”
▪ The UPC is designed to be an avenue for evidence-based
practice innovation within the unit, so it is quite possible
that it will come up with ideas that may change long
time routines
▪ Decisions will be made based on current research and
clinical evidence, clinical practice guidelines, best
practices, etc.
▪ All changes should be driven by the goals of enhancing
the quality of nursing care, improving patient outcomes,
satisfaction, and/or experience, and creating a healthy
work environment for our team
WILL YOUNG NURSES CHANGE THINGS
WITHOUT THE BENEFIT OF EXPERIENCE?
▪ It is critical that the UPC membership is representative
of all staff members on the unit, including both
experienced and less-experienced nursing staff
▪ Whether the experienced staff are UPC members or
constituents, everyone has an equal voice through their
UPC rep and the insight of experience from long time
staff will be taken into consideration
▪ Young nurses are also helpful to have on the UPC
because they are often closest to recent updates to
nursing practice and can bring a fresh perspective and
enthusiasm to the work area
▪ All UPC decisions are made after consulting all members
of the unit and considering everyone’s ideas and
perspectives
WILL MILITARY CONCERNS WILL TRUMP
CIVILIAN CONCERNS?
▪ Every staff member (military or civilian) has an equal
voice on the UPC
▪ Both military and civilian nurses have particular
constraints and interests that should be considered
equally in any decision-making process
▪ However, UPCs have some limits on the
recommendations/decisions they can make – there may
be some issues more appropriately addressed by unit
leadership
▪ The UPC Chair and Co-chair can work with their UPC
Coach and unit leadership to identify those concerns best
dealt with through the UPC and those that should fall
under the purview of the unit’s chain of command
WITH THE RANK STRUCTURE OF THE MILITARY, WILL
SOME UPC MEMBERS BE INTIMIDATED IN LETTING
THEIR VOICES BE HEARD?
▪ Within a UPC, EVERYONE has an equal voice
regardless of rank, experience, or education level
▪ There should be a representative of almost all staff types
within your work environment (RN, LPN, NA, medic,
clerk, tech), as well as a mix of civilian and military
WHAT IS THE ROLE OF THE CNOIC AND
NCOIC IN THE UPC?
▪ Unit leadership has a significant role in unit Shared
Governance, including to:
– Provide vision, guidance, coaching and support for your UPC
– Provide protected time for your UPC to meet
– Maintain dialogue with the UPC while empowering them to
–
come up with recommendations enhancing the quality of
nursing care, improving patient outcomes, satisfaction, and/or
experience, and creating a healthy work environment for the
team
Give the UPC opportunities to update staff during staff
meetings
▪ It may be helpful for unit leadership to join the UPC
meeting (preferably toward the end of the meeting) so
that the UPC can provide updates, ask questions, and
get unit leadership guidance and feedback
AS THE CNOIC / NCOIC, WHAT SAY WILL I
HAVE IN THE DECISIONS BROUGHT FORTH BY
THE
UPC?
▪ Your roles as the leaders of the unit are unchanged
▪ You provide the vision, guidance, and parameters for the UPC
▪
▪
▪
to move forward on ideas and projects
Your leadership challenge is to identify ways to collaborate
with the UPC and give them as much responsibility as possible
while still maintaining proper command and control – this will
take some work by both the unit leadership and the UPC to
figure out a process that works for the team
The UPC has the authority to come up with ideas, do the
research related to those ideas, and formulate
recommendations
Depending on the topic, the UPC must then go back to unit
leadership and/their constituents for final authorization or to
get the issue elevated to a higher level (for example, the
Facility NPC)
I FEEL THE UPC HAS TO DO WHAT I SAY
BECAUSE I AM THE BOSS. IT THAT RIGHT
UNDER THIS MODEL?
▪ The whole point of shared governance is to empower staff
▪
▪
▪
members to become part of the solution, so they feel like their
voice is being heard and they are invested in the success of the
unit (this is a change in philosophy from the previous way that
the Army has practiced)
The UPC should have the freedom to brainstorm evidencebased solutions to issues that enhance the quality of nursing
care, improve patient outcomes, satisfaction, and/or experience,
and create a health work environment for the team (see scope of
focus)
Unit leadership should work collaboratively to implement
those solutions that make sense and coach the UPC on how to
improve/refine recommendations that are not feasible as
submitted
When possible, unit leaders should include their UPC in
solution development – it can actually significantly reduce
leadership workload