Nursing Professional Governance

As long ago as 1988, a national sample of 3,500 nurses identified that being “allowed” to exercise nursing judgment for patient care was one of the most important factors in their practice.

As employees, nurses must structure their practice within rules imposed by their employers, often in the form of policies and procedures that have a profound effect on how nurses deliver patient care. The scope and amount of resources made available by the employing organization further influences their practice. Fortunately, administrators and managers who are also nurses, such as is in Kaiser Permanente, help create these policies and budgets within most health care organizations. However in the past, the nurses who actually delivered care were often absent from policy-making processes and structures. Nursing shared governance emerged as one way to give these clinical nurses equal footing with managers to allow them to participate in the decision-making processes that affect their practice.  Governance is about power, control, authority, and influence. It answers the question in an organization, “Who allocates the hospital’s limited resources?” It surfaced as a radical break from traditional hospital governance where nurses had little power within a rigid formal hierarchical bureaucracy. Nursing professional governance is a managerial innovation that legitimizes nurses’ control over practice, while extending their influence into administrative areas previously controlled only by non-nurse managers.

The 1980s were a heady time for humanizing models, such as participative management and decentralization, which involved people in the organizations. In health care as well as academic environments, shared governance traversed the country, adapting along the way. An evanescent concept, it generated unique structures and processes wherever it was implemented. As an innovation, it arose differently from organization to organization. As administrators adopted the models of early innovators, they changed those programs and adapted them to their own organizational environments. As others later adapted those models, permutations became endless.

Structure is vital to professional governance. In fact, organizations that implement shared governance programs typically create new organizational structures, such as committees. However, it is important to remember that these committees are just vehicles that gather managers and staff together to discuss and make decisions. These committees generally address such issues as practice, management, quality, and education.  However, professional governance is more than a new organizational chart or committee configuration; structures can be deceiving. The number, titles, and arrangements of committees are not as important as the people who make up the membership. Rather, their expertise and knowledge that guides their actions, what they have power to do, and their commitment to both their profession and the mission of their organization are more likely predictors of success. The meaning of success in terms of professional governance and patient care should be the control of practice leading to better patient outcomes.

Focus: It’s About Practice

Nursing professional governance models have always focused on nurses controlling their professional practice. It’s a theme that flows consistently through shared governance research and marketing literature.

The same control over practice characterizes Kaiser Permanente Santa Rosa and some U.S. Magnet hospitals that have put in place formal structures for empowering nurses, such as professional governance programs.

Of course, nurses cannot effectively practice without the right resources – an appropriate amount and mix of caregivers, supplies, and supporting systems. To control practice, nurses must also have some influence over these resources.

Implementation and Issues: Bumps in the Road

The implementation of professional governance has not been easy. It can be riddled with conceptual ambiguity and resistance from the old bureaucratic guard and new professionals struggling to establish their skills. Not everyone will share the enthusiasm for this wonderful innovation. But for those who maintain confidence and keep their eyes on the vision, a rich 25-year plus tradition can help anticipate issues that might arise during implementation by remembering the following insights.

1. Professional governance is a journey, not a destination. Organizations pursuing professional governance move incrementally from past orientations where the few rule to an orientation where many learn to make consensual decisions. Organizations that implement professional governance are in a constant process of revitalization and renewal. There’s always more power to share and more members to bring along on the journey.

2. The journey can be long and steep. Expect a sharp learning curve. Professional governance can be a consciousness-raising event that allows organizational members to thrive. And when the learning curve is past, maintenance will be necessary to keep everyone’s expertise current. Even those who are not directly involved in the model need to be educated and informed, because professional governance affects everyone. Here at Kaiser Permanente Santa Rosa, we have planted the seeds and have seen the fruits of our initial labors.

3. Although not everyone might make the journey, it should be open to all. Professional governance models that include only nurses can become exclusionary and eventually ineffectual by focusing on the goals of a single profession. That is the reason we have included the organization as a whole.