The Center's Guide to Recruitment, Retention and Workforce Development

Shared Governance

The shared governance (SG) concept has a 25-year history, used in over 1,000 U.S. hospitals. Although generally popular and successful, many SG programs fizzled in the 1990’s, the victims of mergers, acquisitions, cost-cutting and an (presumed) abundance of nursing personnel. Workforce shortages, high attrition rates and quality issues have revived interest in shared governance.

Shared governance is a generic term describing any model of participative management or "shared accountability" in which staff nurses share decisionmaking about patient care and nursing practice with management and medical staff. Control over nursing practice is a longstanding issue in nursing, with a goal of better patient outcomes. SG models ensure direct patient care nurses have influence in the development of policies and procedures that affect how patient care is delivered, and in budgeting decisions that determine the amount and scope of resources allocated.

SG is a key characteristic of Magnet Hospitals. (Click here for Forces of Magnetism, a list of organizational elements of magnet hospitals, from AHA’s In Our Hands: How Hospital Leaders Can Build a Thriving Workforce.)

According to Tim Porter-O’Grady, a principal architect of the shared governance movement, SG provides the structural framework necessary for other magnet-type organizational accomplishments to be reached. An empowered organization, Porter-O’Grady believes, is based on four principles:

Partnership
Equity
Accountability
Ownership

Shared governance models determine how those principles operate in a given institution. They present a radical break from traditional bureaucratic, hierarchical management structures. SG redistributes power and influence.

Shared governance models typically fall into three categories:

Councilor models have a coordinating council that integrates decisions made by managers and staff in subcommittees.
Administrative models follow more traditional structures, with separate managerial and clinical decisionmaking tracks.
Congressional models include group voting on issues.

The magic is not in the process or structure, according to Porter-O’Grady, but in the people. Successful outcomes are determined by the expertise and knowledge that SG representatives bring to the table individually, their commitment to their professions and the organization, and in what they have the power to do.

Shared governance models have not all been successful, but the overall track record is impressive. SG programs can be extremely challenging to implement. Advocates stress that SG is a journey, not a destination. The process is organic, changing and adapting to circumstances as they unfold. When staff nurses devote a significant amount of time to meetings, traditional productivity formulas (e.g., man hours per unit of service) may cause concern in the accounting office. The benefits and savings attributed to SG in numerous studies, however, include:

Reduced turnover (and recruitment/orientation costs)
Reduced use of agency staffing
Reduction of management positions
Improved clinical outcomes
Revenue generation up to $500,000 also has been reported in studies analyzing the effectiveness of shared governance.

SG: Not Just for Nurses Anymore . . .

When fully realized, the shared governance concept includes everyone in the organization—including patients, according to nurse educator/author/consultant Robert Hess. Shared governance models that include only nurses can become exclusionary and ineffective, according to Hess, because they tend to focus on the goals of a single profession rather than the organization as a whole. Supporting players on the healthcare team also should participate in decisions that affect clinical and organizational outcomes.

For More Information

Robert Hess’s definitive article, "From Bedroom to Boardroom- Nursing and Shared Governance," is available online at http://www.nursingworld.org/ojin/topic23/tpc23_1.htm

Case histories and Ideas in Action describing successful shared governance programs are included in AONE’s Healthy Work Environments, Volume 2: Striving for Excellence. This volume is the second in AONE's monograph series on the nursing work environment. A total of 21 hospitals and 61 individuals participated in the survey, contributing experiences, best practices and lessons for strengthening the nursing work environment. See pages 40-65. Click here to download the full report.