Shared governance in health care: What is it?
Shared governance is a term that’s getting tossed around health care administration circles and even the mainstream media a lot these days, but very few people outside a select group of subject matter experts know the true meaning of the term. While shared governance as a concept exists in multiple industries, it has become of particular importance in the nursing profession.
Shared governance in nursing can trace its origins to work begun by University of Phoenix alum Tim Porter O’Grady (DM, School of Advanced Studies, 2007) began after he completed his MSN degree way back in 1981. Having been hired as a nurse administrator at St. Joseph’s Hospital of Atlanta, O’Grady wanted to apply some of the research and theories he’d explored in his master’s thesis to his new job.
“One of the big struggles within the nursing profession historically has been the fact that nursing has not been treated as a profession,” says Dr. O’Grady, who also holds multiple undergraduate and graduate degrees in nursing. “It’s been a predominantly female, employee- and job-oriented profession by and large, and as such society has not placed it at the same level as the other professions, such as medicine, nor have employers historically treated it as such.”
O’Grady’s own experience as a staff nurse whose contributions were not equally valued with and by his medical colleagues contributed to his interest in studying shared governance within other professions, and then to apply that concept to nursing. “The mental model of a profession is not employee-based,” he says. “The professions, be they law, medicine, or the like, are largely self-regulated, and practice is driven by the professionals themselves, rather than by some top-down, autocratic employee structure. But our American health care systems were not structured to incorporate nursing as a profession, something which I had seen first-hand could potentially result in patient harm.”
O’Grady explains that shared governance represented a paradigm shift for nurses at St. Joseph’s Hospital of Atlanta and other hospitals that followed in its footsteps. “Shared governance elevates nurses from employees just doing jobs to professionals sharing in health care decisionmaking with other stakeholders,” he says. “It’s horizontal, versus vertical.”
O’Grady defines how professions work versus job-based occupations this way: “The decisions on what constitutes both professional competency and quality practice is governed by the profession itself, and not by employers,” he explains. “That’s how medicine operates, that’s how law operates. The credentialing, licensing, and privileging of these professions is governed and administered by the professionals themselves over their peers via professional boards and organizations. Likewise, human, fiscal, and material accountability is contextual to nursing practice and therefore driven by the organization in partnership with the nursing profession in a shared governance environment.”
However, O’Grady is quick to point out that just because a profession like nursing becomes self-governing, does not mean there is no room for management or employers. “For shared governance to work, there must be a fundamental partnership between the organization and the profession,” he says. “A shared governance structure works because of shared decisionmaking and accountability with management.”
Kim Sharkey, RN, BSN, MBA, is the current Chief Nursing Officer and Vice President of Medicine at St. Joseph’s of Atlanta Hospital, and she was also there in 1981 when Tim Porter O’Grady first began his shared governance work at the hospital. Sharkey emphasizes that O’Grady’s shared-governance work 30 years ago still makes a major impact today. “Our shared governance infrastructure maintains our standards of excellence across the hospital, and those standards originated with the shared governance work Tim Porter O’Grady started way back in 1981,” Sharkey says. “The original shared governance structure has existed basically intact for over 30 years now and has stood the test of time.”
Sharkey agrees with O’Grady’s assertion that making the relationship between nursing and management horizontal rather than vertical is the key to shared governance’s success. “One of the things I always like to point out about shared governance is, the keyword is shared,” she says. “Staff doesn’t have all the power. Instead, both staff and management come together to make decisions and create policies in partnership with one another.”
Beginning with O’Grady’s tenure there from 1981 onward, St. Joseph’s Hospital of Atlanta became one of the leading-edge U.S. health care institutions in terms of implementing a shared governance structure, something which has earned the hospital national and international accolades, including becoming one of the first hospitals in the U.S. to achieve magnet status from the ANCC, as well as designation as a Center of Excellence in the ANCC’s Pathways to Excellence program, and repeated recognition as one of the Top 100 hospitals in the USA by Solucient.
“Shared governance serves as one of the foundations for nursing excellence,” says Sharkey. “Shared-governance organizations generate such a culture of excellence that they frequently achieve the ‘ultimate prize’ — magnet status from the ANCC. I absolutely could not imagine working as a nurse in an environment that does not feature shared governance.”
Kathryn J. McDonagh, RN, PhD, FAAN, is currently Vice President of Executive Relations at Hospira Inc., and she also has experience in shared governance in nursing dating back to the early days at St. Joseph’s of Atlanta, also working with Tim Porter O’Grady. “The shared governance program at St. Joseph’s Hospital of Atlanta was a model for many [other health care organizations] around the country,” says McDonagh. “I have since consulted with many hospitals around the nation to assist them in designing and implementing shared governance models which have resulted in improved patient outcomes, lower costs, reduced nursing turnover, and increased nursing satisfaction.”
While shared-governance organizations frequently achieve the highest nursing accolades and credentials as well as lower costs, they still remain in the minority among American health care organizations. However, more and more health care organizations are seriously considering shared governance, and Vicki M. George, RN, PhD, FAAN, works as an independent consultant that assists them in the process of shifting from a traditional autocratic structure to a more horizontal shared-governance model.
Dr. George defines shared governance this way. “Shared governance is a professional practice model that self-regulates a discipline,” she says. “It forms a culturally diverse and empowering framework, enabling sustainability through bylaws and accountability through outcomes. Decisions of each discipline are aligned through an interdisciplinary structure designed to support excellence in patient care.”
Dr. George often has her work cut out for her when she provides her consulting services to her clients. “My first step when consulting with my clients is to assess their readiness for the new model,” she says. “If it’s an autocratic organization, they’ll have a ways to go. Shared governance is really a maturation process, and a cultural transformation process for the profession of nursing.”
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