A GENERAL THEORY FOR EFFECTIVE MULTILEVEL SHARED GOVERNANCE (GEMS):

A MODEL FOR DRIVING CHANGE IN NURSING PRACTICE

Richard J. Bogue, PhD rjb@courageoushealthcare.com

(407) 376-3740 www.courageoushealthcare.com

M. Lindell Joseph, PhD, RN mlj@courageoushealthcare.com

Session Objectives

• Review Nursing Shared Governance • Describe Development of an operational Theory for Nursing Shared Governance (GEMS)

• Review Initial Results from GEMS • Describe Practice Guidance for GEMS

1. Self-Assessment 2. Process 3. Guide 4. Workshops

Shared Governance • In academia:

• Formal statement by the American Association of University Professors in 1920

• Asserted the importance of faculty involvement “in personnel decisions, selection of administrators, preparation of the budget, and determination of educational policies.”

• In nursing: • First introduced by Christman in1976 • Asserted the idea that nurses should have decision making

power within their scope of practice equal to that of physicians within theirs.

• A component of “magnet hospital recognition” in 1988

State of Evidence on Shared Governance • Shared governance is empowerment and any means of

empowerment. O’Grady (2001, 2003), and widely accepted • It cannot be measured because it is a concept that can take on

many different expressions. O’Grady (2003) • Consequently, no clear guidance for…

• Method of measuring shared governance • Testing theoretical inputs and outcomes of shared governance • Practical, actionable processes based on theory

• However, nursing practice councils are a definitive expression of shared governance. (eg, O’May and Buchan,1999, and many others)

Building Theory for Shared Governance • Sine qua non of SG = More Effective NPCs • Based on multiple studies and using program theory (Lipsey, 1996),

we have developed a theory driven approach to shared governance

• Theory Development Steps 1. What does “effective” mean for NPCs? 2. How can “effective” be measured? 3. What are the inputs to effectiveness? 4. What are theorized outcomes of effectiveness? 5. How can this theory be demonstrated and tested in practice?

Our Starting Place: Nurse Empowerment Draws on Organizational, Team, and Personal Values

More Empowered

Nurses (67%)

ORGANIZATIONAL VALUES Information & Extra-Unit Collaboration (23.90% of variance)

PERSONAL GROWTH VALUES Opportunity & Support (23.82% of variance)

UNIT LEVEL VALUES Resources (19.33 % of variance)

Series of Subsequent Studies # Focus Methods & Measures

1 Initial Validation Survey: Empowerment, Job Satisfaction

2 Power & Personality

Survey, Interviews & Delphi: Leadership Competencies of Goal Attainment, Nurse Personality

3 Inputs & Outcomes

Survey: Leadership Competencies (GA), Sources of Support, Self-Efficacy, Clinical Measures

4 Theory Formalization Lipsey Implementation Theory Development

5 Field Tests of Tools Survey & Interviews: Usefulness and Value of Tools

6 Revision & Validation Survey: Job Satisfaction

Nursing Unit Work Team

•Working toward empowering and aligning goals •Using foundational practices

for effective nursing team work

Nursing Leadership Team

•Ensuring goal clarity & communication •Controlling environmental forces

•Influencing decision making •Using roles and resources

expertly

Critical INPUTS for Effective

Nursing Practice Councils

OUTCOMES of Effective NPCs

Organizational Level

Individual Level

Nursing Work Unit Level

Nursing Department Level

Nurse retention Nurse recruitment

Needed skill sets for service lines

Needed resources Nursing goal attainment

Respect from other disciplines

Care quality Patient safety

Supervisor supportiveness

Self efficacy Job satisfaction

Psychological empowerment

INPUTS and OUTCOMES for Effective Multilevel Shared Governance

Aligning

Team

Foundations

Self-Directing Nursing Teams Advancing Personal Proficiencies, Professional Practices

and Organizational Goals

Ascending Steps To Excellence…

The Staged Competencies of Effective NPCs

® GEMS is a trademark of Courageous Healthcare, Inc.

Demonstrating Leadership for Nursing in Practice Excellence

Self-Defining and Directing a Local Patient Care Improvement Agenda

Advancing Professional Nursing Practice 9

8

7

Achieving the Active Support of Management

Enabling Excellence in Patient Safety Initiatives

4

5 6

Working toward outcomes that help the organization face challenging trends.

Skillfully Managing Group Formation and Tasks

Focusing on Driving Change in Nursing Practice

Establishing Group Identity and Normative Expectations

1

2

3

Empow

ering

Table 1: Summary of Associations with Nursing Practice Council Effectiveness

r† p‡ St± ORGANIZATIONAL LEVEL MEASURES Resources for Goal Attainment (SKAGOAO) 0.562 <0.001 2,3 Organizational Support (POS) 0.563 <0.001 3 Role (nursing central to the organization’s work, SKAGOAO) 0.430 <0.001 2,3 DEPARTMENT LEVEL MEASURES Position (nursing central in communication network, SKAGOAO) 0.584 <0.001 2,3 CNO Communication Competency (SKAGOAO) 0.435 <0.001 2,3 Nursing Department Group Power (SKAGOAO) 0.505 <0.001 2,3 Control of Environmental Forces (SKAGOAO) 0.599 <0.001 2,3 UNIT LEVEL MEASURES Structural Empowerment (CWEQ-II) 0.736 <0.001 1 Co-Worker Support (JCQ) 0.431 <0.001 3 Manager Support (JCQ) 0.588 <0.001 3 Pressure Ulcers (NDNQI) ∆ 0.106 3 INDIVIDUAL LEVEL MEASURES Job Satisfaction (NDNQI) 0.234 0.017 1 Extroversion (Mini Marker) 0.239 0.002 2 Agreeableness (Mini Marker) 0.229 0.003 2 Intellectual Openness (Mini Marker) 0.165 0.037 2 Conscientiousness (Mini Marker) 0.139 0.079 2 Emotional Stability (Mini Marker) 0.114 0.149 2 Self Efficacy (IPIP) 0.200 <0.006 3 †r = Pearson correlation. ‡p = Probability of result, statistical significance ±St refers to Study 1: 2006 (n=119); Study 2: 2008 (n=248); Study 3: 2009-2010 (n=336) ∆ NPCes predicted Pressure Ulcer rates at this significance in regression modeling.

Translating GEMS to Practice • GEMS Self-Assessment

• Use a tested, reliable and valid measure

• GEMS Process • Ensure leadership commitment to principles • Embed purpose-driven practices

• GEMS Guide • Facilitate reflection and self-improvement with the aim of increasing

nursing practice council effectiveness

• Courageous Leadership Workshops • Setting the Stage for Excellence…Top to Bottom & Bottom to Top

Summary

• GEMS is a theory- and purpose-driven approach to shared governance, by which work team empowerment leads to vertical alignment and better outcomes.

• Translations for evidence-based practice: • GEMS Self-Assessment • GEMS Process • GEMS Guide • GEMS Leadership Workshops

References AAUP. Governance of Colleges & Universities. 1920. Web. 1 September 2011. [http://www.aaup.org/AAUP/issues/governance/] American Nurses Association (2003-2011), National Database of Nursing Quality Indicators. (NDNQI). Argyris C. (2004). Reasons and rationalizations: The limits to organizational knowledge. Oxford: University Press. Bogue RJ, Joseph ML & Sieloff CL. (2009). Vertical Alignment of Nursing Group Power and Nurse Practice Council Effectiveness.

Journal of Nursing Management, 17:4-14. (NPCes) Christman L. (1976). The autonomous nursing staff in the hospital. Nursing Administrative Quarterly, 1, 37-4 Eisenberger R., Huntington R., Hutchison S, Sowa D. (1986). Perceived organizational support. Journal of Applied Psychology, 71,

500-507. (POS) Flor R. (2004). Organizational development readiness: Six conditions. Paper presented at the 2005 Capella University

Residency. Abstract retrieved June 13, 2006, from http://www.capellauniversity.edu. International Personality Item Pool: A Scientific Collaboratory for the Development of Advanced Measures of Personality Traits

and Other Individual Differences (http://ipip.ori.org/). Internet Web Site. Joseph ML, Bogue RJ, Thompson J. (2006). Nursing practice councils: A Formative Assessment. Research Report. Florida

Hospital. Kanter R. (1977). Men and Women of the Corporation. New York: Basic Books. Karasek R, Brisson C, Kawakami N, Houtman I, Bongers P, Amick B. J Occup. (1998). The Job Content Questionnaire (JCQ): an

instrument for internationally comparative assessments of psychosocial job characteristics. Health Psychol. Oct;3(4):322-55. (JCQ)

Laschinger HKS, Finegan J, Shamian J, Wilk P, (2001). Impact of struclural and psychological empowerment on job strain in nursing work settings: expanding Kanter's moiicl. J Nurs Adm. 2O01:3U5):26O-272. (CWEQ-II)

Lipsey MW. (1993). Theory as a Method: Small Theories of Treatments. San Francisco: Josey Bass;. New Directions for Program Evaluation, No. 57.

O’May F, Buchan J. (1999). Shared governance: A literature review. International Journal of Nursing Studies, 36(4), 281-300. Porter-O’Grady T. (2001). Is shared governance still relevant? JONA, 31:468–473. Porter-OGrady T. (2003). Research on shared governance: a futility of focus. JONA, 33:251–252. Sieloff CL. (1995). Development of a theory of departmental power in advancing King’s systems framework and theory of goal

attainment. Sage Publications. (SKAGOAO) Saucier G. (1994). Mini-Markers: A brief version of Goldberg's unipolar Big-Five markers. Journal of Personality Assessment, 63,

506-516. (MINI MARKER) Sieloff CL. (2004). Leadership behaviors that foster nursing group power. Journal of Nursing Management. 12, 246-251. Wright TA. (2003). What Every Manager Should Know: Does Personality Help Drive Employee Motivation? The Academy of

Management Executive. 17(2). 131.

A GENERAL THEORY FOR EFFECTIVE MULTILEVEL SHARED GOVERNANCE (GEMS):

A MODEL FOR DRIVING CHANGE IN NURSING PRACTICE

Richard J. Bogue, PhD rjb@courageoushealthcare.com

(407) 376-3740 www.courageoushealthcare.com

M. Lindell Joseph, PhD, RN mlj@courageoushealthcare.com