JONA
Volume 37, Number 12, pp 564-568
Copyright B 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins
THE JOURNAL OF NURSING ADMINISTRATION
Developing Leaders at Every Level
Accountability and Empowerment Actualized Through
Shared Governance
Shelley C. Moore, MSN, RN
Sarah A. Hutchison, BSN, RN
The shortage of frontline nursing staff and their
managers in acute care organizations necessitates
strategies to both use and recognize the unique
knowledge and skills of these individuals. The
authors describe one organization’s successful implementation of a shared decision-making structure
that promotes an empowering work environment
in which professional fulfillment and personal satisfaction can flourish. With support and opportunity,
leaders are developed across all levels of nursing.
As Vanderbilt University Medical Center prepared
to seek Magnet Designation, the shared governance
task force paused to ponder its efforts during the
previous 4 years. At the beginning of this group’s
planned journey, the task force envisioned the revitalization of 20 years’ history of shared governance, the implementation of which had struggled
to keep up with the physical growth of the organization. Built on trust, collaboration, and accountability, our nursing leadership’s shared governance
philosophy has yielded exceptional results.
Shared Governance, Empowerment, and
Staff Satisfaction
What does shared governance have to do with staff
satisfaction? Shared governance at Vanderbilt is
Authors’ Affiliation: Director, Shared Governance Implementation (Ms Moore); Manager, VUH Trauma Center (Ms Hutchison),
Vanderbilt University Medical Center, Nashville, Tennessee.
Corresponding author: Ms Moore, Shared Governance, 1161
21st Avenue, B0102 Medical Center North, Nashville, TN 372322642 (shelley.moore@vanderbilt.edu).
564
about having a ‘‘voice’’Vbeing informed, heard,
and included in decision making. Our success supports Kanter’s1 theory of structural empowerment.
Kanter contends that attitudes and behaviors are
influenced more by social structures in the workplace than by individual personality predispositions. Avenues of power in an organization are the
sources of structural empowerment. These avenues
are (1) access to information, (2) access to resources
necessary to do the job, (3) having the opportunity to learn and grow, and (4) receiving support.
In addition, informal job factors such as alliances
with superiors, peers, and subordinates influence
empowerment.
What difference does empowerment make?
Work settings that are structurally empowering are
likely to increase employees’ feelings of organizational justice, respect, and trust in management.
Perceptions of organizational justice are positively
related to an individual’s commitment to the organization. Respect can be defined as paying attention
to and taking another person seriously. Trust in the
organization represents employees’ belief that an
employer will be honest, open with employees, and
follow through on commitments. These feelings
facilitate professional nursing practice.2 There is a
strong correlation between perceived work empowerment and work satisfaction as well as perceived control over nursing practice.3 The literature
describes several predictors of nurses’ job satisfaction including (1) stress, (2) organizational trust,
(3) communication, (4) autonomy, (5) recognition,
and (6) leadership behaviors.2 There also are relationships between trust in management and nurses’
perceived access to information and support.4
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Nurse managers are ideally positioned to create
positive work conditions that nurture a sense of
empowerment.5 In addition, there is evidence to
support the idea that nurses who perceive their
managers as being influential in the organization
have significantly higher empowerment scores than
those who do not.3 All these factors can lead to
more committed employees who have higher work
satisfaction, predisposing to enhanced quality of
both work life and patient care.
Leader Behavior and Impact on
Staff Empowerment
How can managers empower their staff? Leadership can be defined as the ability to influence a
group toward the achievement of its goals. Facilitative leadership is one strategy that can empower
frontline staff in an organization. Seven practices
of facilitative leadership are (1) sharing an inspiring vision, (2) focusing on results, processes, and
relationships, (3) seeking maximum appropriate involvement, (4) designing pathways to action, (5)
facilitating agreement, (6) coaching for performance, and (7) celebrating achievement. Facilitative
leadership style nurtures staff participation. By involving people in decisions affecting their daily
work experience, facilitative leaders gain people’s
commitment to achieving organizational goals.6 It
stands to reason that frontline staff working in a
facilitative environment are more likely to lead and
influence their peers in the same way.
Work environments that are structurally empowering are apt to have management practices
that enhance mutual respect, communication, trust,
information sharing, and inclusive decision making.
Vanderbilt’s commitment to shared governance
illustrates a leadership philosophy that values a
‘‘voice’’ for staff at all levels. Cultivating this
environment takes time and effort. Once committed
to this philosophy of people working collaboratively
with one another, continuous support and education
needs to be in place to implement and sustain the
culture.
Implementing and Sustaining
A salient characteristic of our shared governance
model is ‘‘dynamic partnerships.’’ The clich2 that
‘‘there is no FI` in Fteam`’’ rings true in our collaborative model. Administrators, managers, physicians, and frontline caregivers are teamed in
various boards, councils, committees, and task
forces to set desired outcomes, make action plans,
take accountability for implementing the actions,
and evaluate process and outcomes. Initiatives are
often cochaired by people of different teams and
entities with a common goal. For example, we have
several multisystem nursing task forces and committees that are cochaired by an individual at the
senior leadership level and an individual at the
middle management levelVusually from different
departments, patient care centers, or institutes.
Other committees and councils are cochaired by 2
individuals who are organizational peers but from
totally different perspectives in the organization.
The groups that they facilitate are interdisciplinary
and diverse. Not only does the practice of cochairing foster development and growth of leaders at all
levels, it ensures that all perspectives are considered. The process also enhances continuity for
patients as they move back and forth between
inpatient and outpatient settings and in different
service departments. In addition, this approach
standardizes the work environment while encouraging creativity and individuality. Group facilitation is
especially practical for licensed professionals because
it continuously shapes best practices as well as
capitalizes on unique strengths and expertise, thus
promoting control over practice.
Believing that our staff nurses on the units, in
the clinics, perioperative, and procedural areas are
key clinical leaders, we have provided them with
tools and education to identify issues where they
are the experts. They are assisted in (1) carefully
planning meeting agendas, (2) gathering and examining data, (3) including appropriate stakeholders
in problem solving, and (4) facilitating consensus
decision making. Identifying a ‘‘fallback’’ mechanism for decision making if consensus cannot be
reached in the preplanned timeframe is important.
Our direct care staff and their respective managers
team together at the local (unit or clinic) level.
Again, there are 2 cochairsVboth at the staff level,
most often registered nurses. One nurse generally
serves as the chairperson and the other as the cochair. This frames a mentoring-type arrangement,
similar to professional organizations’ president and
president-elect structure. The cochairs support one
another and confer with the respective management team to plan agenda and strategize goals,
typically focusing on issues within one or more
of the following realms: (1) quality of patient or
family care and satisfaction, (2) safety, (3) quality
of work life, and (4) education for staff and/or
patients and families. Most of the agenda items
originate from the direct care staff.
Our partnership and team approach is congruent with Kanter’s model of organizational empowerment1 that offers a framework for creating
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565
meaningful work environments, and our experience is that it also develops and cultivates leadership at all levels in the organization. In the midst of
a severe nursing shortage,7,8 we focus particularly
on frontline leaders in our hospitals and clinicsV
nurse managers, assistant managers, charge nurses,
staff educators, and staff nurses. Because these clinical leaders are supported and coached by administrators and other mentors, both mentors and
mentored gain access to information and expertise.
They put plans into action. We strive to assure they
have resources and time to do their work, which
fosters professional growth and learning. This in
turn encourages further empowerment and commitment to the organization. Both accountability and
ownership increase. Key indicators have increased
steadily since 2003 in our staff satisfaction survey
results. These include issues surrounding trust, control over nursing practice, group cohesion, effective
communication, and involvement in decision making, among others.
Strategies to Sustain the Culture
Our recommitment to shared governance during the
past few years employs strategies that echo Kanter’s
avenues of structural empowerment. We have focused
on access to information with education, training,
and multiple lines of communication. We provide
specific support through coaching and networking,
as well as confirmation of support for shared decision making in general from executive leadership.
Access to resources includes convenient classes,
literature, agenda and minute templates, private consultation, and facilitator assistance. There is ample
opportunity for learning and growth. Leadership
abilities thrive.
The shared governance task force concluded
that to invigorate shared decision making in the
organization, particularly at the unit/clinic level,
concentrated attention was needed. A director of
shared governance implementation was hired to
focus on this effort. A program coordinator was
added to support logistics as well as to assist with
system-wide agenda planning and meeting coordination. Another major accomplishment of the
shared governance task force has been to bring
our Nursing Bylaws back to the forefront. The
Bylaws are thoroughly reviewed and revised by
nurses at every level in the organization, resulting
in a highly interactive Nursing Bylaws Convention
every other year.
Using the shared governance task force for
guidance, the shared governance implementation
staff facilitates training and educational activities
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for staff and managers learning how to organize
and conduct productive meetings and how to start/
maintain shared governance mechanisms at the
local level. To jump-start training, we sent more
than 250 staff members to an outside workshop
called ‘‘The 4 Ps of Effective MeetingsVPurpose,
People, Performance and Processes.’’9 Currently,
our own human resource department provides similar training. A critical piece to the education process
was to develop a 4-hour workshop entitled ‘‘Board
Basics’’ that contains an overview of shared governance and the basic ingredients to start and maintain local level decision making. This course begins
a coaching relationship between the shared governance implementation staff and the workshop attendees. They go back to their units to apply what
they learn in order to refine shared decision making
in their clinical areas. Continued coaching is available. A monthly shared governance support group
lends further assistance to these teams. Three of the
most popular monthly support group sessions have
been (1) evidence-based practice, (2) personality
styles, and (3) panel discussionVwherein the panel
experts are staff leaders. Most sessions offer contact
hours. Additional workshops to address specific issues are available through human resources. Two
examples are (1) Managing Workplace Negativity
and (2) Building Trust. Skilled facilitators from our
learning center department are also available for
specific consultation.
Concerted efforts have been required to encourage inpatient, procedural, and outpatient areas
to initiate and sustain local boards. Many areas
that already had a board needed to revamp. In
several areas, much transformation has occurred.
Because shared governance is a continuum, people
need to be met where they are on their journey
and coached to progress to the next point. A key
mechanism has been developing a communication
tree as well as a shared intranet portal to allow for
networking and comparison of best practices and
processes. Celebrating achievements and efforts
through recognition has been motivating. The
shared governance implementation staff personally
attend as many local board meetings as possible,
following up with debriefings. There was also
much celebration of success witnessed as we prepared for our Magnet site visit. Recognition is part
of our culture.
Further acknowledgment of the value of this
work and those making it successful occurs by inviting staff leaders to attend select Nursing Leadership Academy (The Advisory Board Company)
workshops. Staff who attend the Academy with
their management teams receive affirmation to
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the partnership that is the centerpiece of our
shared governance model. These opportunities also
augment skill building and feelings of accountability. Three of these sessions well attended by staff
leaders are (1) ‘‘Negotiation Workshop: Maximizing
Gains by Pursuing Shared Interests,’’ (2) ‘‘Managing Conflict: Bridging Individual Differences for
Improved Performance,’’ and (3) ‘‘Strengthening
Nurse-Physician RelationshipsVCultivating a Collaborative Clinical Network.’’10
All implementation strategies meet a criterion
for workplace empowerment. A strategy either enhances access to information, access to resources,
support for the work, opportunity to develop, or a
combination of these. In addition to making recommendations for implementation efforts, the shared
governance task force actively engages in evaluation of implementation. This is done by conducting face-to-face interviews of unit and clinic board
chairs and managers together every year. These
data are analyzed along with staff satisfaction,
group cohesion, control over practice, and various
focus group data to identify opportunities for improvement. Other evaluation instruments are being
investigated.
Our executive leadership also is leading an aggressive journey to establish new service standards.
This is being done by setting organizational ‘‘pillar’’
goals, measuring performance, adhering to a standard of professional and personal behavior, and
building a working environment that stimulates
staff to grow while acting on behalf of our patients
and families to make a difference. The specific
problem solving done at the unit level fits easily
into the pillar format (people, service, quality,
growth and finance).11 These pillars provide a
common language for all. With the availability of
data on quality, patient satisfaction, and staff
satisfaction, the shared governance structure provides forums for continuous improvement within
each pillar. An effective shared governance structure is one method of laying the foundation to
achieve the Forces of Magnetism as well. Thus, all
organizational endeavors are synergistic and transparent rather than standing in separate silos.
Implications
Although new forecasts regarding the nursing
shortage by 2020 are less severe than previously
estimated (340,000 vs 800,000), this new forecast
still constitutes a number 3 times larger than the
peak of the registered nurse shortage in 2001.12,13
Nursing workforce literature recommends 7 key
strategies to combat this problem, 2 of which are
(1) fix problems associated with a negative work-
place climate through promoting involvement in
decision making and propagating collaborative
relationships with physicians and management
and (2) keep the long-term in mind by focusing
on improving the workforce environment, to encourage registered nurses who enter the nursing
workforce to stay and those who expect to retire in
the near future to postpone.7 The nurse manager
plays a key role as chief retention officer, mentor,
coach, and facilitative frontline leader. Retaining
this valuable resource is put at risk by increasing
nurse manager stress, particularly in acute care
settings.8 The work environment is critical. Administrators must endeavor to create supportive and
empowering work environments for nurse managers and staff nurses alikeVthe nursing shortage
affects all nursing roles. Strengthening and aligning
our precious human capital resources with partnership models is crucially important in recruitment
and retention of qualified people into ever-changing
and highly complex healthcare settings. Interdisciplinary and collaborative relationships are key strategies to defuse stress, spread out accountability,
solve problems, and keep communication productive and open.
Summary
We should strive continuously to enhance our work
environment. A study linking empowerment to
magnet hospital characteristics found higher perceptions of autonomy and control over nursing
practice in addition to positive nurse-physician
relationships.14 Strategies leading to these satisfiers
will assist healthcare organizations to meet the
demand for direct care nurses and the development
of facilitative leaders needed to create a positive
work environment. In the spirit of continuous improvement and professionalism, healthcare organizations must never stop seeking ways to engender a
satisfying and fulfilling workplace.
Acknowledgments
The authors thank Nancy Wells, DNSc, RN,
FAAN, Director of Nursing Research, for help in
preparing this article; Robin Steaban, MSN, RN,
Administrator Cardiovascular Services, for leadership in shared governance over many years;
Marilyn Dubree, MSN, RN, Chief Nursing Officer,
for supporting an environment within which professional empowerment and leadership development can flourish; and Vanderbilt University
Medical Center for caring about a positive work
environment.
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567
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