Shared governance: a children’s hospital journey to clinical nursing excellence

Abstract

Background

Shared governance is examined through a framework for developing independent decision making in professional nursing practice and improving patient care outcomes.

Aims

This study is designed to obtain a baseline measurement of the degree of shared governance in a selected children’s hospital in Saudi Arabia.

Methods

The study was guided by the Donabedian model. The Professional Nursing Governance Index was used. A total of 400 questionnaires were distributed to nurses working at the hospital, with a response rate of 77% (n = 307). Descriptive and inferential statistics were used for analysis.

Results

The results corresponded with those from nurses and managers in most subscales of the Index of Professional Nursing Governance (information, goals, resources, participation and practice). However, nurses working in the operating theatre and surgical unit have a perceived higher level of shared governance than those in critical care units and medical wards.

Conclusions

The results could encourage shareholders and leaders in the nursing field to develop the perception of shared governance by adopting a shared governance model, which in turn might improve the quality of nursing care.

Introduction

Shared governance is represented by a structural model that enables nurses to have control over their practice (Alrwaihi et al., 2018; Lamoureux et al., 2014). Anthony (2004) and Overcash et al. (2012) argued that shared governance is a model where a group of associates direct, govern and regulate work through goal-oriented efforts in their organisation.

Applying a shared governance framework is claimed to improve the provision of good-quality care (Alrwaihi et al., 2018, Barden et al., 2011). This develops collaborative relationships between healthcare professionals, improving quality of care and overall clinical effectiveness; it increases staff confidence; supports professional skills; raises professional profiles; leads to improved communication; builds on original knowledge and skills; improves professionalism and accountability; increases direction and focus; and reduces duplication of effort to achieve excellence in Nursing (Barden et al., 2011; Overcash et al., 2012).

Excellence is the dynamic process that integrates the best theoretical and practice knowledge in each patient encounter. Nursing excellence was further associated with outstanding results in patient satisfaction and nurse retention, where shared governance was the vehicle used to integrate the excellence standards of Magnet accreditation to achieve optimal health outcomes for the patient, nurses and system (Van Oyen, 2004).

Literature review

Shared governance was seen as a way of introducing empowerment and building structures for funding it (Alrwaihi et al., 2018; Powers and Bacon, 2106). It is applied as a management process model that authorizes and encourages the engagement of nursing staff in decision making, with the purpose of improving their professional practice (Prince, 1997).

A shared governance model for nursing has long been recognised as an effective leadership approach for improving the working environment by supporting nurses in having greater autonomy and responsibility for the regulation of their work and practice (Alrwaihi et al., 2018; Porter-O’Grady, 2001).

Nurses should be involved in decision making affecting their professionalism, allowing them to be involved in controlling work issues, schedules and reviews – currently the province of managers (Barden et al., 2011; Powers and Bacon, 2106). Shared governance embraces four principles: partnership, accountability, equity and ownership (Porter-O’Grady, 2001). It may be structured using different models, including unit-based governance, which generally refers to governance derived from a nursing unit; councillor governance, which refers to decisions made by hospital-wide councils of nurses; administrative governance, which considers executive rule as leadership intended for smaller nursing councils; and congressional governance, which considers that all nursing staff work to form cabinets responsible for controlling training (Alrwaihi et al., 2018; Anthony, 2004; Overcash et al., 2012; Porter-O’Grady, 2001). These models have been reported to increase professional nurses’ contribution to operational practice and policy making, as well as demonstrating their responsibility in the expansion of work schedules (Bretschneider et al., 2010).

Barden et al. (2011), Alrwaihi et al. (2018), and Joseph and Bogue (2016) argued that shared governance can be considered as a framework or a system that supports and empowers nurses in their workplace, and as a managerial structure that facilitates staff members in making clinical decisions, thus increasing their satisfaction. As a result, shared governance implementation leads to a satisfactory working environment for nurses (Overcash et al., 2012; Powers and Bacon, 2106).

Shared governance gives nurses control over their professional practice, providing structure and context for healthcare delivery (Mahmoud, 2016). This in turn can improve the rate of patients’ satisfaction and strengthen nurses’ authority (Barden et al., 2011). The model of professionally shared governance affects the quality of care positively through the structure it provides (Bumgarner and Beard, 2003; Kramer et al., 2009; Hess, 2011; Laschinger et al., 2003; Overcash et al., 2012; Powers and Bacon, 2106).

The outcomes of shared governance are difficult to measure, including whether or not the practice is truly in place within an organisation (Porter-O’Grady, 2001). The governance structure is required to ensure that the principles of shared decision making are boosted, but structure alone is not considered shared governance (Anderson, 2011). According to Anderson, “the concept is more than a structure; the philosophy of professional accountability must be implemented” (Anderson, 2011: 198); hence, the measure of governance is critical in evaluating outcomes and assessing the level of implementation. Studying nursing concepts systematically to be suitable for implementation is a prerequisite to promoting professional nursing practice (Joseph and Bogue, 2016).

In Saudi Arabia, limited evidence exists to assess shared governance in nursing, specifically for children and young people’s services. This study aimed to obtain a baseline measurement of the shared governance level in a selected children and young people’s hospital in Riyadh, the capital of Saudi Arabia. The specific aims were to:

• Assess the level of shared governance in a children and young people’s hospital.

• Examine the differences of shared governance level among nurses in a children and young people’s hospital.

Methods

Design

A descriptive study design was used. This study was conducted within a traditional leadership environment where decisions were made commonly by managers, and shared governance councils were yet to be implemented. This work focussed on assessing the current status of an empowerment structure as a prerequisite of the American Nurses Credentialing Center (ANCC) Magnet Recognition Program in the hospital. Data were collected using a self-report questionnaire from nursing staff and managers in different units, including medical, surgical, critical care and the operating theatre, in the largest public children’s hospital in Riyadh. The selected hospital is a 300-bed capacity facility, providing both in- and outpatient haematology/oncology services to children. Prior to data collection, Institutional Review Board approval was obtained from the selected hospital.

Potential participants were approached in person by researchers and invited to complete the study survey in a private room away from the clinical area. Following agreement from the senior nursing leadership, the questionnaire was distributed during the last hour of the working shift. Participants and their units were selected randomly from the list of names provided by the nursing administration in the hospital. Participants were informed about the purposes of the study. They were provided with the questionnaire along with a cover letter explaining the purposes of the study.

The participants had full disclosure about the risks and benefits of the study. They were also assured that participation was voluntary and they could withdraw from the study at any time without any penalty (for example, it would not affect their performance evaluation in the hospital). In addition, they were assured that all the information obtained would be anonymised by assigning numbers to each participant’s questionnaire, keeping it in a locked location and deleting the data completely once the study was concluded. Questionnaires were completed and returned at the end of the working shift. Data were collected from August 2018 to October 2018.

Sample and setting

The target population of this study included all nurses currently employed in the selected hospital (n = 400) and able to understand written English. The estimated sample size was calculated using the Power Primer (Cohen, 1992). The test revealed that, using a desired power of 0.80, medium effect size (r = 0.25) and 0.05 level of significance, the estimated sample size was 250 nurses; over-sampling was targetted to account for attrition rate. A convenience sample of the 307 of 400 nurses filled out and returned the self-reporting questionnaire, with a response rate of 76.8%, which included their demographic profile. Participant selection aimed to enhance the heterogeneity of the respondents, recognising that nurses were represented by different cultural, and socio-economic backgrounds.

The inclusion criteria comprised all nurses who are working in hospital units including not limited to (for example) medical, surgical, critical care and the operating theatre, and who understand the English language.

Measurements

Data were collected using the Index of Professional Nursing Governance (IPNG) developed by Hess (1998). The IPNG was established to “measure the distribution of control, influence, power, and authority” (Hess, 2011: 236). It produces an overall score of governance for organisations, in addition to measuring readiness through an aggregate score for individual levels of management, units and departments (Hess, 2011). The IPNG was designed to rank organisational professional governance as traditional governance, shared governance or self-governance. According to Hess, organisations implementing shared governance should achieve a minimum total score of 173.

The IPNG comprises 86 questions measuring levels of reported governance among healthcare personnel on a scale from traditional, to shared and self-governance. The scores are founded on a 5-point Likert-like response scale: 1 = nursing management/administration only; 2 = primarily nursing management/administration with some staff nurse input; 3 = equally shared by staff nurses and nursing management/administration; 4 = primarily staff nurses with some nursing management/administration; and 5 = staff nurses only. Scores 1 and 2 indicate decision making dominated by management/administration, and 4 and 5 indicate more staff nurse participation in decision making. The IPNG range of total scores reflecting a traditional, hierarchical decision-making environment is 86–172. An environment of decision making shared by nurses at different management levels would have an IPNG range of 173–344. If nurses are the decision-making group, then the IPNG score range would be 345–430.

The six subscales of the index are: (1) nursing personnel, with 22 items assessing who controls the personnel, and their structures; (2) information, of 15 items related to who has access to the information connected to governance activities; (3) resources, of 13 items related to who influences practice; (4) participation, of 12 items related to who contributes to structures connected to governance activities at different structural levels; (5) practice, of 16 items assessing who controls proficient practice; and (6) goals, of 8 items related to who sets and negotiates the resolution of conflict at different organizational levels.

Reliability and validity of the Index of Professional Nursing Governance

A total of 40 nurses participated in a pilot study to check for understanding, clarity and the time required for completing the questionnaire. The Donabedian (1988) model was used to guide the development of the instrument. This provides a framework for examining healthcare services, assessing their quality in three categories: structure, process and outcomes. Structure includes location, hospital buildings, staff, finance and equipment. Process shows the relationship between patients and providers throughout the delivery of healthcare. Finally, outcomes refer to the healthcare properties and effect on the health status (Donabedian, 1988).

The pilot study was conducted in three departments of the hospital. A list was obtained from the hospital departments, then for each clinical ward/unit, the questionnaire was distributed according to the number of nurses. The Cronbach’s coefficient alpha for the IPNG scale was 0.90.

Data analysis

The Statistical Package for the Social Sciences (SPSS) (version 17.0) was used for analysis. Data were screened, and no missing values or outliers were found. Data were suitable for descriptive and inferential statistics. To lower the risk of a type I error, the statistical significance level was accepted at p < 0.05. In addition, the risk of a type II error was lowered by increasing the sample size and using a power of 0.80.

Results

The sample was predominantly female (96.7%, n = 297). Two-thirds of the participants (66.1%, n = 203) were educated to baccalaureate level and the majority held the position of staff nurse (73.3%, n = 225) (see Table 1).

Table 1.

Sociodemographic data of participants (n = 307).

Variable	No.	%
Gender
Male	10	3.3
Female	297	96.7
Education level
Diploma	77	25.1
Baccalaureate	203	66.1
Master	27	8.8
Management position
Nurse staff	225	73.3
Nurse manager	82	26.7
Working units
Medical	89	29
Surgical	90	29.3
Critical Care	83	27
Operating Theatre	45	14.7

IPNG

The total IPNG score was 183.85 for the entire population, which is within the shared governance range (173–344). Likewise, all subscale scores were consistent with levels of shared governance, namely that nurses reported that decision making is shared between themselves and administration in all subscales except personnel.

For the subscales, the nursing personnel mean score was 37.89, which is below the range expected for shared governance (44–88), reflecting little shift toward including staff nurses in the decision-making process. For the other subscales, participants’ scores reflect that the shared governance model had been implemented recently. In relation to information (who has access to governance activities information), respondents reported a mean score of 34.9, falling within the shared governance range (31–60); the goals subscale (related to who sets goals and negotiates resolution of conflict at different organisational levels) had a mean score of 17.58, on the borderline of the shared governance range (17–32). Resources (who supports professional practice that impacts resources) showed a mean score of 31.18, within the shared governance range (27–52). Participation (who develops and participates in structures like the governance committee) had a mean score of 25.27, on the borderline of the shared governance range (25–48). Lastly, practice (who controls professional practice) had a mean score of 37.02, which falls within the shared governance range (33–64) (see Table 2).

Table 2.

Descriptive statistics for the six Index of Professional Nursing Governance (IPNG) summative subscales (n = 307).

Subscale	Shared governance range	Mean	SD	Minimum	Maximum
Total IPNG Score	173–344	183.85	40.95852	100	322
1. Personnel	44–88	37.8925	13.15338	22	83
2. Information	31–60	34.8990	9.26125	15	60
3. Goals	17–32	17.5798	5.59785	8	34
4. Resources	27–52	31.1824	8.48408	13	58
5. Participation	25–48	25.2736	7.28348	12	51
6. Practice	33–64	37.0195	9.08779	16	97

One-way ANOVA was used to identify whether there was a significant difference associated with reporting of shared governance levels and specific occupation. The results showed a significant difference between nurses regarding the shared governance level according to working units (i.e. medical, surgical, critical care, operating theatre) (F = 2.191, p = 0.018) (see Table 3).

Table 3.

Index of Professional Nursing Governance (IPNG) total score by Unit, One-way ANOVA (n = 307).

Unit	Mean	SD	F	Significance
Medical	184.23	35.603
Surgical	188.17	46.256	2.191	0.018
Critical care	183.70	40.613
Operating theatre	209.21	52.688

The Scheffe post hoc test indicated a statistically significant difference between surgical and medical units toward the surgical unit (p = 0.047), and between the operating theatre and critical care toward the operating theatre (p = 0.034) (see Table 4).

Table 4.

Post hoc test results (n = 307).

(I) Unit	(J) Unit	Mean difference (I – J)	Standard error	Significance
Medical	Surgical	19.10575	9.56890	0.047
	Critical care	49.32308	19.62278	0.12
	Operating room	20.52593	9.78204	0.37
Surgical	Medical	19.10575	9.56890	0.047
	Critical care	48.33333	18.94285	0. 11
	Operating room	21.71474	9.78498	0.27
Critical care	Medical	49.32308	19.62278	0.12
	Surgical	48.33333	18.94285	0. 11
	Operating room	−25.51786	12.00722	0.034
Operating theatre	Medical	20.52593	9.78204	0.37
	Surgical	21.71474	9.78498	0.27
	Critical care	−25.51786	12.00722	0.034

Discussion

The results of this study indicate the IPNG measure (Hess, 1998) is a suitable tool for measuring shared governance decision making. The current study is the first in Saudi Arabia to assess the shared governance level at a children’s hospital. Shared governance was reported by nurses at different management levels within the satisfactory IPNG range of 173–344, excluding the personnel subscale, where nurses reported limited control over their professional decision-making practice.

Hospitals are constantly looking for opportunities to improve their performance by providing quality-based, and cost-containment care (Powers and Bacon, 2106; Wilson et al., 2014). To enhance nursing care and progress the health setting’s overall performance, shared governance has been combined with nursing infrastructures to provide a framework. Shared governance infrastructure has the ability to provide nurses with the opportunity to be partners in nursing management, to reach optimal patient and job satisfaction, productivity, and reduced turnover of staff (Al-Faouri et al., 2014; Powers and Bacon, 2106).

Shared governance range

Many studies have reported lower, borderline results in the shared governance range (Al-Faouri et al., 2014; Anderson, 2011; Barden et al., 2011; Lamoureux et al., 2014). The rationale might be related to poor participation in multi-functional shared services, and the absence the transformational leadership to mediate the relationship between structurally empowering working conditions and patient-care quality (Bamford-Wade and Moss, 2010). It could be associated with hospital nurses carrying out isolated, routine tasks, rather than using their professional training because they are subject to control by organisational and medical divisions of labour. The environment may disturb a nurse’s ability to practice according to professional standards.

Personnel subscale

The results revealed that, in the nursing personnel subscale, nurses reported limited control over their professional practice in their formal organisation; this subscale had the lowest mean score of all the subscales, indicating that decisions are not shared equally by staff nurses and nursing management. Hess (1998) reported that only 1 of 16 hospitals had acceptable shared governance in nursing personnel scores. Similarly, Barden et al. (2011) and Overcash et al. (2012) found that nursing reports of their working environment were more closely related to a traditional governance structure. However, in Jordan, nurses reported that the practice of shared governance is more professional when the environment provides opportunities and structural empowerment through resources, support and information (Afeef et al., 2010).

Information subscale

In the current study, nurses identified additional access to information in areas such as resources, fresh advances in nursing practice, compliance of the hospital in terms of nursing practice with requirements for measurement of agencies, and strategic plans for the coming years. Participation in quality activities, an orientation program for new nurses, an annual training plan for the nursing departments and access to library facilities within the hospital might explain the results. These findings (mean = 32) were consistent with other studies (Afeef et al., 2010). and fall within the shared governance ranges of Wilson et al. (2014).

Goals subscale

In relation to questions about who sets the goals and negotiates the resolution of conflict at different organisational levels, the mean score of 17.58 fell within the lower limit of the shared governance range (17–32). These results are consistent with the mean scores of other studies e.g. Afeef et al. (2010) (mean 17), Lamoureux et al. (2014) (mean 16), and Wilson et al. (2014) (mean 18). Mahmoud (2016) recommends that engaging nurses in decision making, work redesign and conflict resolution could improve their empowerment. Therefore, nurses need more knowledge and training regarding conflict negotiation strategies to improve their ability to advocate for, and provide quality care to, patients.

Resources subscale

The mean score of 31.18 remained higher than five facilities previously surveyed by Hess (1998) and which were characterised as shared governance hospitals. The participants in the present study have formal authority in a variety of procedures such as everyday patient care, consulting services and creating schedules, the means confirming those from earlier studies. Other studies revealed similar results e.g. Afeef et al, (2010) (mean 32), Lamoureux et al. (2014) (mean 33.5) and Wilson et al. (2014) (mean 34.8).

Participation subscale

The mean score for participation in the current study was 25.27, just within the shared governance range (25–48). The nurses stated a limited ability to participate in committees that relate to strategic planning, multidisciplinary professionalism, organisational budgets and expenses. However, they had shared ability with nursing management/administration to participate on most committees, particularly those related to clinical practices within the unit, and staff scheduling.

Practice subscale

Nurses reported adequate input in the parts of the healthcare system that directly touch on patient care (mean 37.2); for example, standards of patient care, improvement of care quality, progress in health education, products for the nursing care plan and integrating research in nursing. Nevertheless, they reported incomplete control over the model of nursing care for their professional work and staffing levels. The rationale for this reporting could be related to the active role of accreditation drivers, which gives an opportunity for nurses to contribute to categorising and reviewing the patient-care standards needed, and to apply quality improvement projects and the implementation of evidence-based practice projects recently introduced into the hospital. The result is consistent with Afeef et al. (2010), where the mean score was 37.

Conclusion

The findings of this study showed that the nurses’ decision making is shared by staff and managers in the majority of IPNG subscales (information, goals, resources, participation and practice). The nurses working in operating theatres and surgical units reported more shared governance than nurses in critical care units and medical wards. There was no difference between nurses at staff and manager level regarding shared governance level. The study has implications for improving nurses’ working environments and enhancing shared governance. These findings can be used as recommendations for shareholders and nursing leaders to implement a suitable model of shared governance inside hospitals. Furthermore, research using focus groups to discuss shared governance in nursing practice might identify the challenges handled by many nurses, and lead to essential interventions.

Limitations

Considering the importance of the issue studied, the limitations of this study must be considered in interpreting the results. The study involved a small sample of nurses from four units, and the findings may not be representative of the level of shared governance among nurses in other settings. In addition, this study was limited to one hospital located in Riyadh - the capital, which limits the external validity of the findings. Future research should include additional studies with a larger sample size recruited from other hospital settings. More descriptive and longitudinal studies are still needed to gain a comprehensive understanding of the outcomes of shared governance in Saudi hospitals. This is an important step before moving to interventional studies. Polit and Beck (2010) advised that interventions often fail because they are designed without an adequate understanding of the problem or the relationship between variables.

Recommendations

Meanwhile, according to the literature, there is insufficient study of Saudi children’s hospitals discussing this issue; nursing educators need to focus more on the concept of shared governance and decision-making involvement for their students. Availability of training in shared governance skills for all nurses, and especially for nurse managers, is a requirement. Administrators can use the findings of this study to progress or support models for shared governance, training nurses and nurse managers about shared governance and decisional involvement behaviours and how they affect nurses’ job satisfaction. Implementation of certain skills by nurse managers might lead to a new environment of organisational culture, encouraging a mood of creativity in conflict, direct management, group-work, autonomy, a sense of motivation and empowerment. Thus, the integrated shared governance model may serve as a valuable tool for organisations to achieve optimal health outcomes for the patient, nurses and system. Qualitative methodology is still needed to gain a comprehensive understanding of the shared governance model in children’s’ hospitals.

Key points for policy, practice and/or research

• Nurses in Saudi children’s and young people's hospitals need more awareness with regards to the shared governance concept.

• Stakeholders and nursing leaders may adopt a suitable model of shared governance in children’s hospitals using the findings of this study.

• The principles of shared governance provide a model of structural empowerment commonly used to integrate the Magnet accreditation standards to achieve desirable patient, nurse and system outcomes.

Biography

Omar Khraisat is an Assistant Professor, Former Assistant Dean for Training Affairs. PhD from the University of Jordan. Research focus is on pediatric palliative care, quality of care, patient safety, and community health nursing.

Khetam Al-awamreh is an Associate Professor, former Chairperson of the Maternal and Child Health Department at the Faculty of Nursing. Research focus is on the maternal and child health nursing.

Mahmoud Hamdan is a Director of the Magnet Program. His research focus is on the quality of care, and patient safety.

Mohammed AL-Bashtawy is a Full Professor, Former Dean of Nursing College. Research focus is on community health nursing.

Abdullah Al khawaldeh is an Associate Professor, Former Dean of Nursing College. Research focus is on community health nursing.

Mohammad Alqudah is a Clinical Instructor. Research focus is on youth mental and psychological health.

Jamal A. S. Qaddumi is an Assistant Professor. Research focus is on the quality of care.

Samer Haliq is a Lecturer. Research focus is on quality of care, patient safety, and emergency services.