Abstract
Shared governance is a structural model for framing professional practice within an organizational format. After 25 years of research and development, basic principles that undergird the appropriate and sustaining structures of shared governance have become well established. Understanding, translating, and applying these principles will help those implementing nursing shared governance to build a strong professional structure, which can serve as a framework for constructing and expressing professional practices, processes, and relationships.
In the 30 years since the first nursing shared governance structures were created in hospitals, emerging research has validated many of the conceptual foundations regarding the management of knowledge workers (Porter-O'Grady, 2009). At the time, shared governance concepts were developed within the context of professional self-management; notions of the unique characteristics and needs of knowledge workers were just beginning to emerge (Porter-O'Grady & Finnigan, 1985). Although research on the unique organizational considerations for managing and relating to knowledge workers is yet unfolding, many of the foundations already laid belie many of the traditional management approaches to this unique group (Fray, 2011).
Shared governance in nursing was originally conceived by Virginia Cleland in the 1970s as a framework for nursing governance in union-organized health settings. She believed at the time that collective bargaining was central to the self-direction of the nursing profession and that a newer framework was needed for relating professionals to the organization while maintaining professional autonomy. In Dr. Cleland's mind, shared governance was central to creating a balance between union, profession, and organization (Cleland, 1978).
As it turned out, collective bargaining did not gain as strong a foothold in the nursing profession as Dr. Cleland and her colleagues originally imagined. In fact, fewer than 8% of nurses were organized under collective bargaining agreements in the United States (U.S. Bureau of Labor Statistics, 2010). Although collective bargaining was not broadly embraced by professional nursing leadership, the need for constructing an organizational and structural frame for governing nursing as a profession remained as an important characteristic of the growth and maturation of the nursing profession. It is a testament to the timeliness and appropriateness of creating a professional structural frame for nursing that shared governance has become part of the common language of the profession and a normative expectation of how the profession of nursing conducts its professional business and manages the organizational life of the discipline.
Still, much about the foundations of shared governance and the essential principles and components that guide its legitimacy and development is only marginally understood by nursing leadership. The unique difference in structuring and managing knowledge work and knowledge workers explicated by scholarly exploration in the past 15–20 years has had only minimal impact on the governance, structuring, and management models in nursing organizations (Porter-O'Grady, 2001). Many of the organizational structures and management processes in professional nursing services across the globe still reflect industrially based, vertically oriented, hierarchical employee work group models in managing and relating to nursing professionals (Pink, 2009). Even though there is significant evidence of the failure of such models in the management of knowledge workers, health care has been excruciatingly, even perversely, reluctant to shed those organizational frames and management behaviors. As a result, the ever-present conflict between existing employee work group organizational and management approaches and the autonomy and accountability demands grounded in the exercise of truly professional behaviors is often seen in nursing organizations (Porter-O'Grady, 2010).
It is a testament to the timeliness and appropriateness of creating a professional structural frame for nursing that shared governance has become part of the common language of the profession and a normative expectation of how the profession of nursing conducts its professional business and manages the organizational life of the discipline.
Although the other predominant professions in American society (law, medicine, architecture, engineering, etc.) developed interdependent models representing horizontally structured, accountability-grounded partnerships during most of the 21st century, the nursing profession has developed as a subset of hospital organizations and, to a smaller extent, public health systems. Indeed, many of the struggles in establishing nursing professional autonomy and accountability parallel the political and social structures of women's efforts to obtain equity in a predominantly paternalistic social context (Ashley, 1976). Today, although much progress has been made in the political and social empowerment of women, most social and service institutions throughout the United States are still predominantly owned, led, or managed by men in numbers that clearly demonstrate a long and consistent pattern of gender inequity (Eagly & Carli, 2007). The challenges in creating a professional structure for nursing that parallels the structure and relationship of the other major professions in American society are a clear demonstration of the many barriers that nursing leaders still confront. Efforts to create an effective shared governance professional structure face gender inequity, historic role subordination to another discipline, traditional hierarchical management models, internally generated oppressed group behaviors, and the related paucity of demonstration of the nurse's impact in generating revenue and advancing the net aggregate value of the health system (Malloch & Porter-O'Grady, 2009).
It is a testament to strong nursing leadership in the past 25 years and the effectiveness of nursing-led organizational imperatives such as the American Nurses Credentialing Center's (ANCC; 2010) Magnet Program that improve and advance quality that the centrality of structural empowerment (nursing professional governance) to the advancement of sustaining excellence has become a model for the professional nursing organization. The last two decades have shown that a sustainable trajectory of improved, accountable professional behavior cannot be obtained over time without the prevailing and supportive infrastructure, which supports it (Porter-O'Grady, 2009). Early scholars in organizational and systems science discerned this essential relationship between sustainable behavioral change in the knowledge worker and the organizational infrastructure, which enables (or disables) it (Bennet & Bennet, 2010). This symbiotic relationship between structure and behavior provides the cornerstone for establishing a continuing productive and renewing partnership between profession and organization. It also serves as the cornerstone for professional shared governance models.
Even though there is significant evidence of the failure of industrially based, vertically oriented, hierarchical employee work group models, health care has been excruciatingly, even perversely, reluctant to shed those organizational frames and management behaviors.
The Needs of the Knowledge Worker
There are several things that we know the knowledge worker needs to be able to fully express his or her role and to obtain full value for membership in the professional community (Silberman, 2007). In contrast to employee work groups, on-the-job learning and training for the work role is generally not the foundation of the professional role and its application. Knowledge workers generally master a body of knowledge essential to their role prior to assuming positions, which express the role. Therefore, professional workers are unique in that they own their own knowledge. That knowledge is portable; the knowledge they obtain is central to their perception of themselves and their value. The source of their contribution is the interaction between the individual knowledge worker, his or her unique body of knowledge, and the expression of the role (Bennet & Bennet, 2010).
Furthermore, professional workers are generally agents of a culturally constructed social mandate. They are usually licensed in their respective states to fulfill certain social obligations on behalf of society; that licensure derives from the authority society invests in the state. Professionals generally do not owe accountability for their role to the organization in which they work. Rather, that accountability is driven by the sanction of the state on behalf of society. Control of the parameters and obligations of professionals generally rests with society, through the state, and prevents the workplace from unilaterally controlling the regulations, requirements, and accountability of the role. That accountability is invested in the individual and the professional membership community and is regulated by the state. If this differentiation is fully understood and articulated within the work frame, shared governance as an organizational structure for professional practice exemplifies that frame insofar as it reflects the partnership between the professional, the profession, and the organization within which the profession practices. Shared governance reflects this foundational understanding of professional stakeholders to the extent that their relationship to the organization is a partnership, not a dependency.
For the individual professional, social accountability demands a strong awareness of autonomy regarding his or her role and its relationship to the profession and the organization. The role of the professional is therefore not a job, task, function, or set of activities, as would be ascribed to employee work groups. Instead, the professional reflects the characteristics associated with the knowledge worker insofar as the individual sees practice as an expression of the work of the profession and a personal fulfillment of its social mandate. The professional nurse therefore is accountable more than responsible; focuses on the relationship between process and impact rather than on function; and is predominantly concerned with advancing, improving, and achieving excellence in practice in the interests of furthering social health. Because these elements are the foundations of professional practice, the organizational structure must be constructed to obtain and sustain them.
Shared Governance as a Structure for Professional Practice
To ensure that accountability stays invested in the profession and its practitioners, the organizational structure must be designed in a way that creates no impediment to this local locus of control, but instead, enables it. The professional ownership of that practice must never shift out of the hands of those who practice. When that accountability shifts to the management or the organization, it assumes an illegitimate locus of control and ensures the creation of an infrastructure that actually impedes legitimate expressions of accountability. Managers cannot drive practice, own accountability for practice, or obtain the outcomes of practice in a professional framework. Accountability requires ownership and can only be expressed legitimately, effectively, and sustainably by those who own the accountability for doing professional work. Therefore, the organizational structure must be designed in a way that ensures that the primary accountability for professional practice, resting in the individual practitioner, cannot move into the hands of those with whom that locus of control is not legitimately located (Maki, 2010).
The structure of shared governance contains a foundational tenet—recognizing that the professional owns the accountabilities for practice, quality, competence, and the generation of knowledge. These accountabilities cannot be owned, driven, controlled, or directed by institutions, managers, consultants, or advisers. To the extent that the accountability, which rests with the practitioner, shifts to those peripheral agents, conditions are created that ensure that nursing accountability can never be legitimately fulfilled. When the accountability moves away from its legitimate locus of control in the professional practicing staff, it ceases to meet the legitimate requisites and obligations for its expression, negatively affecting the potential for achieving and sustaining the related outcomes. This contradiction and conflict underpins much of the failure to achieve higher levels of quality, patient safety, performance expectations, and programmatic sustainability of care initiatives not driven by those who own the products of professional accountability.
Professional workers are unique in that they own their own knowledge. That knowledge is portable; the knowledge they obtain is central to their perception of themselves and their value.
For these fundamental reasons embedded in all the professions, the design of the profession in relationship to the organizations of which it is a part affirms the independent and unilateral accountability of the profession to define its practice, measure and control its quality, determine and validate the expectations for the competence of its peers, and generate and validate knowledge (research) in the interest of those it serves (Timmermans & Oh, 2010). Indeed, these activities are the partnership obligations that the discipline brings to the relationship it establishes with the organization with which it partners and the contribution it makes to the value of their relationship. It is these same principles of professional ownership of practice and partnership with the organization in shared governance that are being applied to the structuring of the profession of nursing.
Of course, the journey to this more horizontal, equitable partnership orientation between nursing profession and organization is more difficult, constrained by the history of institutional control, employee work group orientation, gender inequity, subordinating functional perceptions, and vertical/hierarchical design of the organizational infrastructure (Cowen & Moorhead, 2011). Therefore, movement to true accountability, partnership, equity, and impact must follow a different developmental trajectory and involve the establishment of a unique framework for the growth and maturation of the nursing profession. Shared governance provides the structural framework within which that process can progressively unfold.
The Five Principles that Sustain Shared Governance
Twenty-five years of history in conceptualizing, designing, actualizing, and studying the application of shared governance in nursing organizations have yielded some quickly apparent principles. On the road to demonstrating the character, content, and behavior of nursing professionals in organizations of excellence, we have learned much about what makes them both work and thrive. Even as we begin to reconfigure the next stages of health care in which collateral (equity-based and horizontal) interprofessional team-based models of accountable care will be the foundations of health service, the principles which govern professional practice will continue to be essential (Winowiecki et al., 2011). For these interprofessional teams to work effectively, professional principles which govern their practice and relationships will be essential to their collateral and mutual success.
Principle 1: Professions Are Driven by Practice and Practitioners
A centerpiece of professional shared governance is the understanding that where the locus of control for decision making regarding practice, quality, competence, and knowledge generation does not rest with practitioners and/or is not driven by their capacity to make decisions and undertake change, they are unsustainable. To the extent that decisions related to local professional accountability are made at a distance from the points of service by those who do not practice there, the higher the cost of those decisions, the greater the risk of nonaccountability and the lower the chance for sustainability of the outcomes (Taguchi, 1986). Knowledge work organizations must be designed for distributed decision making in a way that ensures true expression of legitimate accountability and creates the essential decision/action partnerships with knowledge workers (professionals) that represent their mutual investment and ownership in decisions, design, and actions reflecting accountability-driven outcomes.
Shared governance has demonstrated that when structure aligns with expectations regarding relationships and performance, and when ownership resides at the point of service, positive work, relationships, and outcomes are generated and sustained.
Principle 2: It's about Structure
Unless there is direct alignment between organizational structure and intended behaviors, the discordance between the two will negatively affect both the work and its potential to achieve sustainable outcomes. This historic discordance between the employee work group-driven health care organizational structure and its professional workers has done nothing to add value or to create conditions that advance accountability, performance, and excellence. In almost all research about effective knowledge work, traditional vertical, hierarchical, management-driven, policy-controlled, and functionally structured models of work have failed to raise performance, advance outcomes, or generate sustainable success (Leon, 2011; Tunis, 2007). Shared governance has demonstrated that when structure aligns with expectations regarding relationships and performance, and when ownership resides at the point of service, positive work, relationships, and outcomes are generated and sustained (Aiken, 2011; Hess, 2011a, 2011b). The real surprise here is that the use and relevance of this data does so little to inform the mechanisms of management of knowledge work professionals.
Principle 3: Accountability is the Centerpiece of Professional Work
There is much conversation about the centrality of accountability to professional practice. Indeed, much lip service is given to the demand for accountability and the requisites of accountability in the professional workplace. The problem is that most of the demand for accountability comes from management/ leadership and from places in the organization where the products of accountability cannot be directly derived. Managers can plead for accountability, demand accountability, teach accountability, expect accountability, and even demonstrate personal accountability and still not obtain accountable performance from knowledge workers (professionals). The locus for the ownership of accountability in practice belongs to the practitioner—indeed, is embedded in the life of practice. If practice accountability is the foundational expectation for professional performance, it must be owned, articulated, driven, performed, and measured by practitioners from whom it is generated and from where its products are derived. Shared governance creates a structure in which the locus of control for practitioners ‘personal and professional accountability is constrained from moving from its legitimate location at the point of service. The structure of the organization/profession is designed such that it is difficult for accountability to escape its legitimate locus of control. Accountability abhors ambiguity. Therefore, there must be clear alignment between the expectations of accountable performance and the structures which locate, demand, and reward it and minimize the potential for failure to deliver.
Accountability abhors ambiguity. Therefore, there must be clear alignment between the expectations of accountable performance and the structures, which locate, demand, and reward it and minimize the potential for failure to deliver.
Principle 4: Appropriate Locus of Control for Accountability Must be Designed into the Shared Governance Structure
In this principle, the foundations of locus of control elucidate the distinctions between professional and management/organizational accountabilities. Within the shared governance conceptual framework, accountability for practice, quality, competence, and knowledge generation fall under the exclusive purview of the profession and its practitioners. In shared governance, the organization, institution, and managers have no originating accountability for professional practice, quality, competence, and knowledge generation. Instead, the institution, organization, and management have particular and distinct accountabilities, which enable the profession to do its work and facilitate the partnership between person and organization that is essential to advancing the mutual interests of both. Organizational accountabilities and management obligations are identified in these contextual accountability frames. These management accountabilities (called contextual accountabilities)—human, fiscal, material, support, and systems accountabilities—provide and define the framework, supports, and resource relationships necessary to advance the work of the organization. These management accountabilities support the practice of the partner professions, merging management accountabilities with professional accountabilities to advance purpose and patient care. These distinct but shared accountabilities provide the foundation for stakeholder partnerships to advance their requisite strategies, alignments, negotiations, adjustments, accommodations, conflict dynamics, and mutual goal setting.
Clearly, the leadership methodologies necessary to manage a distributed decision-making environment in which equity, ownership, investment, mutuality, and stakeholder engagement are critical competencies make for a new organizational frame of reference, structure, and set of relational dynamics. In short, they demand real and competent collateral and collaborative leadership.
Principle 5: Management Leadership is Critical to Shared Governance Effectiveness
Often, rumors emerge that the structures of shared governance are designed to diminish or sideline the role of the manager in a professional organization. Nothing could be further from the truth. In fact, management leadership is critical to the success of effective shared governance models. The caveat here is that management leadership requires a particular set of competencies that demonstrate an understanding of how to lead professional knowledge work environments and how to actualize competency in a distributed decision-making structure. Much of traditional management behavior in nursing organizations has more closely resembled social family systems applications (parenting) than they have exhibited true professional leadership. Leadership requires a different set of competencies and skills in equity-based, knowledge-driven, adult-to-adult, peer-related professional environments than those found in vertically oriented, hierarchical, controlling, employee work group environments. Effective servant leadership skills, a deep understanding of complexity leadership applications, and the capacity to translate professional role and performance characteristics in a broader health service organizational context are needed in shared governance environments. Conceiving, constructing, and leading an interdisciplinary, peer-based, professional practice organization requires a strong partnership-oriented, collateral set of leadership skills operating in a dynamic and complex organizational infrastructure. Rather than fewer managers in shared governance environments, there is a need for strong, competent, effective management leadership that can work well in a collateral, collaborative, and partnership-oriented organizational environment (Porter-O'Grady, 2009).
Conceiving, constructing, and leading an interdisciplinary, peer-based, professional practice organization requires a strong partnership-oriented, collateral set of leadership skills operating in a dynamic and complex organizational infrastructure.
Certainly, the challenges of evolving into in mature professional discipline with the organizational infrastructure to support it is neither quick nor easy work. Still, if the professional practice of nursing is to mature in a way that reflects equitable and parallel delineations of social, economic, political, and role value, the work of professionalizing the relationships and interactions of the nursing profession must be fully engaged. It is essential to embrace the next-step realities of a challenging and hard-won history of growth, development, and maturation of the nursing profession over the past 100 years. The work of structural empowerment as manifested in nursing shared governance is simply the contemporary work of our day. It serves as a part of the preparation for the next stage in advancing the practice of nursing and in fulfilling the full potential of the contribution the profession has to make in the interests of those it serves. Building on what we know, constructing structures that enable and support accountable professional practice is simply one of a host of connections that must be synthesized to achieve full professional potential. The times suggest that laying these foundations is the right work as nursing begins to assume rightful partnership with physicians and other clinical disciplines in writing a new script for the future of health care delivery and for advancing the health of those we serve.
Footnotes
Tim Porter-O'Grady, DM, EdD, APRN, FAAN, is a senior partner at Tim Porter-O'Grady Associates, Inc; associate professor and leadership scholar in the College of Nursing and Health Innovation, Arizona State University in Phoenix, Arizona; clinical professor and leadership scholar in the College of Nursing at Ohio State University in Columbus, Ohio; and visiting professor in the School of Nursing at the University of Maryland in Baltimore, Maryland.