Please Help me

If you are assuming the persona of Ms. Sally Brook, Vice President of Nursing, and a relatively new addition to Holy Family Hospital's executive team. In your past position at another institution, the Nursing Department eagerly adopted a form of distributed leadership known as shared governance. By all accounts, the transition to shared governance was perceived as being largely successful. Since shared governance was successful at your previous organization, you floated the idea of adopting shared governance at Holy Family Hospital by the Executive Director and Chief Medical Officer. To your surprise, they expressed skepticism, but for different reasons. When you shared the idea of implementing shared governance in Nursing, your management and supervisory teams were less than enthusiastic. Realizing that initiatives of this magnitude require the unwavering support of the leadership team.Reading the case provided below answer the following questions

Answer these questions inregeards to the case provided below.

1. What is the introduction?
2. What is the evidence?
3. What are the facts?
4. What is the reasoning?
5. What does shared governance look like in nursing?
6. What are the intended and unintended consequences of implementing shared governance in an organization case?
7. What are potential barriers to the successful implementation of shared governance (e.g., workplace politics, conflicting agendas, resistance to change, threat to power, etc.)?
8. Strategies for overcoming resistance to organizational change.
9. Is a shared governance as a solution at holy family?
10. How should she proceed?

Here is the Case!!

Restructuring Decision Making at Holy Family Hospital

Overcoming Resistance to a Shared Governance Program

Kent V. Rondeau

University of Alberta, Edmonton, Alberta, Canada

Sally Brooks, RN, MSN, was baffled and just a bit angry. Her great effort to introduce shared governance and distributed leadership for the nursing staff at Holy Family Hospital was being met with indifference by many and with downright hostility by the rest. She could not understand the resistance from nurses and physicians to even consider adopting a new approach that she believed would dramatically revolutionize clinical decision making at the hospital. Shared governance is an important new initiative--the aim of which is to distribute decision-making authority more widely to hospital nursing staff. By creating new organizational structures and by implementing a directed professional practice model that would more fully engage, enable, and empower her staff, Brooks believes she would be able to more effectively utilize their full scope of talents and experiences. After all, she thought, "Doesn't everyone want more power and authority at work?"

As the newly hired vice president for Nursing Care at Holy Family Hospital, Brooks was eager to make her mark in the 440-bed community general hospital by promoting and adopting what she considered

"progressive management practices." As a nursing leader in her previous job, she had seen the power of shared governance in action. Indeed, shared governance works by dispersing decision-making authority to a larger cadre of employees, typically involving nurses, physicians, and administrators who hold membership in a governing council, or on its various committees. The rationale for distributing leadership more widely in the hospital is that, by empowering employees to engage in activities outside traditional job descriptions, artificially imposed organizational silos and rigid occupational hierarchies that affect quality of care can be eliminated. Through staff engagement and commitment programs such as shared governance, people begin to take more responsibility for the things they do and develop an appreciation for the larger picture that is often seen as external to their traditional fields of responsibility.

In her previous employment at a large and prestigious teaching hospital, shared governance and other forms of distributed leadership were well-regarded practices with a proven track record of success.

Accordingly, she believed the practice of shared governance would be easily accepted at Holy Family. When Brooks thought about the power of this progressive innovation to change the organization and its people in a positive and dramatic way, she reflected on her own personal leadership journey. "It was really through shared governance that I began to see its promise for tapping the full potential of nursing staff, as well as enhancing my own role in the process," she thought. "It was my involvement with this program that exposed me to my own leadership abilities and talents. Without this exposure, I would not be where I am today."

While Brooks was fully committed to introducing shared governance to all nursing staff, she was also keen to extend it further by involving the medical staff and administration. The hospital executive director, Roger Steele, was generally supportive of the idea of distributed leadership at Holy Family if it would improve patient care quality and reduce operating costs. However, he was concerned that shared governance might slow decision making by creating additional bureaucratic hurdles. Indeed, the last accreditation review noted that Holy Family "suffers from slow and convoluted decision making as a consequence of having too many administrative committees with little coordination among them."

The physicians were highly supportive of efforts to improve patient care quality at Holy Family, but worried that the potential of programs like shared governance would not improve communication between doctors and nurses. Dr. Stan Jonas, the chief of staff, was on record as being frustrated by the quality of the relationships between the hospital's physicians and nursing staff, which had become increasingly strained in recent years. Dr. Jonas stated his position on the matter rather succinctly: "Nurses have to remember that they are here to serve patient needs and carry out the commands of the attending physicians by working in ways consistent with their legally mandated scope-of-practice.

INTRODUCING SHARED GOVERNANCE TO THE NURSING STAFF

The meeting with her nursing staff at which Brooks introduced the idea of a shared governance approach to manage clinical decision making at Holy Family Hospital did not go well. As she thought back, she realized the staff concerns were a laundry list of reasons why it shouldn't be done. One nurse manager stated she had read somewhere that the track record on nursing shared governance was decidedly mixed. Another said a local nursing home had tried to introduce it a few years ago and abandoned shared governance after it didn't work.

"I don't think we should be pursuing theoretical approaches to management unless there is convincing evidence they work in practice," she declared.

One experienced nurse reminded the group she had "no free time" to participate in the program; patient care responsibilities, administrative duties, and dealing with demanding doctors filled her day. "I can't meet after my shift as I have family responsibilities," she claimed. Another asked if she had to do extra work to serve on a shared governance committee and if she would be paid extra for her participation. "I don't think I'm paid enough as it is, given all that I do around here."

One young nurse hired in the past year stated she was "too new" and didn't have enough experience in managing complex care for very ill patients. "I don't feel competent enough to make decisions that could affect whether someone lives or dies," she stated. A senior nurse with over 30 years of experience at Holy Family commented that doctors have always made the real decisions around here. "They won't cede any clinical decision making power to us. Anyway, I don't see why we have to change how things are done as the system has worked pretty well for us in the past, hasn't it?" Another nurse asked what would happen if the shared governance committee made one decision and it was overruled by the director of nursing or by the hospital administration. "I don't want to serve if I don't have any real power," she asserted.

A nursing aide asked if the members of a shared governance committee could be held accountable and legally liable for decisions that turned out bad. "If that's the case, I don't want any part of this program!" Two nurse ward managers asked about the limits on decision-making authority under a shared governance model.

"In what areas will we have a say and will we be restricted from having input on things that are really important to us?" An experienced nurse remarked that she doubted hospital administration and staff physicians would ever participate in structural changes aimed at curtailing their decision-making authority.

"I've been around here for over ten years and I know that the 'suits' and especially the 'docs' are never going to give nurses more power!"

One senior nurse manager openly questioned the wisdom of allowing junior staff to make important decisions when they haven't earned their spurs. "I have worked hard to become a nurse manager here, done lots of committee work, gone back to school for my MBA, and stuff like that. I don't think it's fair that others should be given authority when they have not earned it," she declared.

The nurse union representative cautioned everyone that false ideas like distributed leadership programs are really management's way of "extracting more work off the backs of workers. Anyway, it's the responsibility of management and the doctors to make decisions, and not us. That's why they make the big bucks, isn't it?" Furthermore, she claimed that programs like shared governance were "illegal" because they operate outside the collective bargaining process, and are really meant to circumvent that process. "If management tries to establish this program here, you can be sure that our union will grieve it," she asserted.

Finally, one elderly nurse nearing retirement stated that, in her day, ideas like distributed leadership and shared governance "would not pass muster." "I think that we too easily get caught up in every little new thing that comes along. This stuff is entirely unproven and is just another stupid management fad that will soon pass. Just ignore it and it will go away!"

As Brooks braced herself against the onslaught of resistance to shared governance, she recalled all the reasons to implement it at Holy Family. Her belief in the benefits of shared governance gained from witnessing it firsthand at her previous place of employment provided her with confidence that it had the power to transform what she perceived as a rigid, authoritarian, top-down culture at Holy Family. Brooks believes the "physician-centered" ways of doing things at Holy Family silenced, submerged, and subordinated nurses under physician control and dominance. "We cannot improve patient care quality here until we have liberated all the human capital of our nursing staff. Shared governance is the means to do just that!"

SHARED GOVERNANCE AS A SOLUTION AT HOLY FAMILY?

Shared governance in management involves an administrative body through which a group of employees exercises its full authority based on their knowledge, skills, and experience. It refers to a group decision-making process that is cast on the bedrock of professional collegiality, egalitarianism, workplace democracy, and shared accountability for the outcomes of those decisions. A broadly shared governance structure describes a partnership between managers and clinical staff, including physicians and other healthcare providers. An underlying premise of shared governance is that staff nurses at every level of the organization should govern their professional practice while being included in all decisions that directly or indirectly affect their patients. Two assumptions are often associated with this form of clinical decision making: first, previous forms of governance will be distributed from traditional managers to clinical staff following the implementation of shared governance, and second, it assumes that nurses, generally, want to be full participants in decisions that affect them.

From a managerial perspective, shared governance is complementary to a number of high-involvement employee work practices, including self-managing work teams, continuous quality improvement teams, nursing crosstraining programs, and employee suggestion programs. All these programs require fully engaging providers in the totality of the work enterprise. Nurse empowerment is considered the means by which this engagement occurs because those with the relevant knowledge need to inform decision making since they operate at "the-point-of-care." Shared governance involves a nurse empowerment structure that articulates this requirement because nurses (along with other healthcare providers) operate extensively at this interface.

The literature on shared governance suggests it involves a dynamic structure focused on four critical principles: equity, partnership, ownership, and accountability. Equity refers to integration of the nursing duties and roles needed to achieve common goals based on the willingness of each member to contribute to the greater good. Partnership requires development of relationships among diverse staff to promote mutual respect, effective communication, and enhanced collaboration to achieve organizational objectives. The principle of ownership refers to recognition by the individual of the value of their efforts, knowledge, and aptitudes to organizational performance, while accountability involves a willingness to invest in decision making that produces a shared sense of responsibility for individual and collective outcomes. Nursing shared governance is a managerial innovation that legitimizes nurses' control over their practice while extending their influence into administrative areas previously controlled by administrators and clinical areas under the purview of physicians.

Shared governance is not a new idea. Indeed, in the past three decades, forms of it have been implemented with varying degrees of success. Its implementation has been euphemistically described as "very tricky" and akin to "pinning Jell-O to a wall." The shift from traditional models of nursing practice to one of shared governance involves structural change. Indeed, structure is vital to making shared governance work.

Healthcare organizations that implement nursing shared governance create organizational structures or permanent committees that address issues such as nursing practice, administration, quality of care, research, and education.

Three primary models of shared governance have emerged in practice. The councilor model is the most common. Here, a coordinating council integrates clinical and administrative decisions made by managers, physicians, and nursing staff holding membership on various subcommittees. The administrative model continues the traditional bureaucratic structure but splits the organizational chart into two tracks with either an administrative or a clinical focus-although membership in both tracks usually includes managers and staff as implementation progresses. Third is the congressional model, which maintains the traditional structure but empowers nurses to vote on issues as a group.

Does shared governance work? There is evidence it has the potential to provide significant benefits to the organization and its nurses. Nevertheless, many healthcare organizations have been unable to realize them.

Many studies of the effectiveness of shared governance lack conceptual and methodological rigor that makes it difficult to draw definitive conclusions. Their conclusions draw on anecdotal evidence of success with subjective appraisals of outcomes that include better relationships and team harmony, fewer job-related conflicts, greater job and career satisfaction, improved communication, collaboration, personal and professional growth, and lower turnover. A major problem in determining the effectiveness of shared governance is the absence of valid and reliable standards assessing the extent to which its principles and practices are embedded in the organization. Multiple definitions and conceptualizations of shared governance make comparing studies difficult. A shared governance program in one healthcare organization may be structurally dissimilar and engage decision-making spheres differently than shared governance in another.

A major benefit touted by proponents of shared governance is its potential to improve the work environment of nurses, as well as their satisfaction and retention. A few case studies of single organizations report benefits to nursing, but definitive empirical information of implementing shared governance is mixed.

Although some anecdotal cases report improvement in the nursing work environment when autonomy, communication, and practice are consistent with professional ideals, these results have not been consistent over the range of studies with multiple designs, sampling, and measurement strategies. Evidence that shared governance leads to improved team dynamics, such as team cohesion, commitment, and conflict resolution, is also somewhat mixed. Similar to evaluation of other outcomes of shared governance, consistent relationships between shared governance and nurse satisfaction have not been found. In some instances, nurse satisfaction was found to improve when shared governance was implemented; other studies reported no change, or a decrease in nurse satisfaction.

An important contributing factor in explaining the failure of shared governance to realize many of its performance enhancements may be that, as a care delivery model, it requires a major shift in how organizations are typically managed. Most proponents of shared governance stress the need for a supportive organizational culture in which it can take root. Shared governance is a way of conceptualizing workplace democracy and empowerment and includes new structures that must be created to support and extend it. As such, it usually requires changes involving a significant transition as to how managers, nurses, physicians, and organizational systems interact. Part of the journey in implementing shared governance is the high degree of emergent learning that will take place along the way. Implementing structural, process, and cultural changes in complex dynamic systems cannot be mapped precisely before the process has begun. It has been stated that implementing this kind of change is like "opening a door into the soul of the organization. You really don't know exactly where it is going to take you or what you will encounter along the way!"

ADDRESSING RESISTANCE TO SHARED GOVERNANCE AT HOLY FAMILY

HOSPITAL

Comforted by her belief in the totality of benefits that could be derived by implementing shared governance at Holy Family, Brooks was, nonetheless, distressed as she thought about how she might proceed and how to answer the questions from the nurses who were reluctant to embrace it. Brooks knows that shared governance requires a strong, supportive culture and strong leadership that will nourish its implementation. Of the six nurse managers at the meeting, two offered only mild support for the idea, while the others were highly skeptical that it could be implemented successfully. An important factor present at Holy Family is a strong, top-down autocratic culture that seems to stifle management innovation. Historically, most important decisions were made by hospital administrators and physicians. Nurses were expected to perform their clinical duties and had narrow, clearly defined, predetermined circumstances in which they could exercise discretion.

Nurses had never questioned the existing power structure. Indeed, most nurses had grown comfortable with the status quo in which they worked under rigid scope-of-practice limits.

Brooks knew nurses at Holy Family were deeply suspicious of her motivation for introducing shared governance. The previous director of nursing had tried unsuccessfully to implement a number of management reforms, including nurse self-scheduling, job-sharing, self-managing nursing teams, and a cross-training initiative. All the initiatives were introduced with great fanfare but were abandoned soon after their introduction because they were not working. Often these innovations were abandoned after criticism by a few vocal nurses or by the nurses' union and never had a chance to take root. The hospital had used significant resources to train staff for their new roles and had even purchased a new software program to help nurses job-share and self-schedule their work shifts. Quietly, however, administration made known its skepticism that these "innovations" would significantly reduce nursing costs and improve patient care quality. In retrospect, the impetus for implementing these initiatives followed soon after a consultant's management study showing nurses suffered from problems of morale, stress, burnout, and absenteeism, all of which led to costly turnover.

The hospital board was alarmed by the findings and mandated that the executive director do something to address the issues. However, hospital management never seemed fully committed to addressing the problems with the nursing staff.

As Brooks thought about her next meeting with the nursing staff she contemplated how she might reduce the reticence and resistance to the shared governance initiative. She remembered a quote from a paper she had read about employee involvement programs: "We presume that nurses want to participate in decision making, but this assumption is not valid ... if nurses have authority for decision making, that does not mean they will choose to exercise it." She wondered if empowerment was one of those ideas that is "good in theory" but

"unworkable in practice." She wondered if she were trying to introduce the program too quickly, or without sufficiently preparing her staff for change. "Maybe I can make the program voluntary and only involve those who want to participate," she thought. "Would that even be workable because it is contrary to the central tenets of shared governance?"

She knew that shared governance required a compatible organizational culture and that the top-down culture at Holy Family was incompatible. She wondered if she should first change the culture to make it more compatible with shared governance before introducing it, or should she introduce shared governance to leverage the needed cultural change? She understood she would be able to choose the shape and model of shared governance that fits the needs at Holy Family. "Perhaps we can start the process by involving the nursing staff, or perhaps just the nursing staff on a single unit. Then, if it works, add the hospital administration and physicians," she thought. Yet she wondered if there is enough benefit to be gained if the hospital administration and physicians are not involved from the beginning.

She wondered about the prospect of winning the support for the program from nurses, only later to have it rejected by the physicians and senior management. While the hospital executive director and chief of medical staff remain skeptical with respect to the benefits of distributed leadership, she knew her strongest resistance came from her nursing staff, most notably the nurse managers and supervisory staff, who feared that shared governance might make their jobs redundant. As she contemplated a new strategy to win nursing's approval and support and find a way to make it happen, she was bolstered by her unshaken belief that shared governance was the best way to transform nursing practice at Holy Family. Given the rough landscape ahead, how should she proceed?