Developing Leaders at Every Level

Transcription

1 JONA Volume 37, Number 12, pp Copyright B 2007 Wolters Kluwer Health Lippincott Williams & Wilkins THE JOURNAL OF NURSING ADMINISTRATION Developing Leaders at Every Level Accountability and Empowerment Actualized Through Shared Governance Shelley C. Moore, MSN, RN Sarah A. Hutchison, BSN, RN The shortage of frontline nursing staff and their managers in acute care organizations necessitates strategies to both use and recognize the unique knowledge and skills of these individuals. The authors describe one organization s successful implementation of a shared decision-making structure that promotes an empowering work environment in which professional fulfillment and personal satisfaction can flourish. With support and opportunity, leaders are developed across all levels of nursing. As Vanderbilt University Medical Center prepared to seek Magnet Designation, the shared governance task force paused to ponder its efforts during the previous 4 years. At the beginning of this group s planned journey, the task force envisioned the revitalization of 20 years history of shared governance, the implementation of which had struggled to keep up with the physical growth of the organization. Built on trust, collaboration, and accountability, our nursing leadership s shared governance philosophy has yielded exceptional results. Shared Governance, Empowerment, and Staff Satisfaction What does shared governance have to do with staff satisfaction? Shared governance at Vanderbilt is Authors Affiliation: Director, Shared Governance Implementation (Ms Moore); Manager, VUH Trauma Center (Ms Hutchison), Vanderbilt University Medical Center, Nashville, Tennessee. Corresponding author: Ms Moore, Shared Governance, st Avenue, B0102 Medical Center North, Nashville, TN (shelley.moore@vanderbilt.edu). about having a voice Vbeing informed, heard, and included in decision making. Our success supports Kanter s 1 theory of structural empowerment. Kanter contends that attitudes and behaviors are influenced more by social structures in the workplace than by individual personality predispositions. Avenues of power in an organization are the sources of structural empowerment. These avenues are (1) access to information, (2) access to resources necessary to do the job, (3) having the opportunity to learn and grow, and (4) receiving support. In addition, informal job factors such as alliances with superiors, peers, and subordinates influence empowerment. What difference does empowerment make? Work settings that are structurally empowering are likely to increase employees feelings of organizational justice, respect, and trust in management. Perceptions of organizational justice are positively related to an individual s commitment to the organization. Respect can be defined as paying attention to and taking another person seriously. Trust in the organization represents employees belief that an employer will be honest, open with employees, and follow through on commitments. These feelings facilitate professional nursing practice. 2 There is a strong correlation between perceived work empowerment and work satisfaction as well as perceived control over nursing practice. 3 The literature describes several predictors of nurses job satisfaction including (1) stress, (2) organizational trust, (3) communication, (4) autonomy, (5) recognition, and (6) leadership behaviors. 2 There also are relationships between trust in management and nurses perceived access to information and support JONA Vol. 37, No. 12 December 2007

2 Nurse managers are ideally positioned to create positive work conditions that nurture a sense of empowerment. 5 In addition, there is evidence to support the idea that nurses who perceive their managers as being influential in the organization have significantly higher empowerment scores than those who do not. 3 All these factors can lead to more committed employees who have higher work satisfaction, predisposing to enhanced quality of both work life and patient care. Leader Behavior and Impact on Staff Empowerment How can managers empower their staff? Leadership can be defined as the ability to influence a group toward the achievement of its goals. Facilitative leadership is one strategy that can empower frontline staff in an organization. Seven practices of facilitative leadership are (1) sharing an inspiring vision, (2) focusing on results, processes, and relationships, (3) seeking maximum appropriate involvement, (4) designing pathways to action, (5) facilitating agreement, (6) coaching for performance, and (7) celebrating achievement. Facilitative leadership style nurtures staff participation. By involving people in decisions affecting their daily work experience, facilitative leaders gain people s commitment to achieving organizational goals. 6 It stands to reason that frontline staff working in a facilitative environment are more likely to lead and influence their peers in the same way. Work environments that are structurally empowering are apt to have management practices that enhance mutual respect, communication, trust, information sharing, and inclusive decision making. Vanderbilt s commitment to shared governance illustrates a leadership philosophy that values a voice for staff at all levels. Cultivating this environment takes time and effort. Once committed to this philosophy of people working collaboratively with one another, continuous support and education needs to be in place to implement and sustain the culture. Implementing and Sustaining A salient characteristic of our shared governance model is dynamic partnerships. The clich2 that there is no FI` in Fteam` rings true in our collaborative model. Administrators, managers, physicians, and frontline caregivers are teamed in various boards, councils, committees, and task forces to set desired outcomes, make action plans, take accountability for implementing the actions, and evaluate process and outcomes. Initiatives are often cochaired by people of different teams and entities with a common goal. For example, we have several multisystem nursing task forces and committees that are cochaired by an individual at the senior leadership level and an individual at the middle management levelvusually from different departments, patient care centers, or institutes. Other committees and councils are cochaired by 2 individuals who are organizational peers but from totally different perspectives in the organization. The groups that they facilitate are interdisciplinary and diverse. Not only does the practice of cochairing foster development and growth of leaders at all levels, it ensures that all perspectives are considered. The process also enhances continuity for patients as they move back and forth between inpatient and outpatient settings and in different service departments. In addition, this approach standardizes the work environment while encouraging creativity and individuality. Group facilitation is especially practical for licensed professionals because it continuously shapes best practices as well as capitalizes on unique strengths and expertise, thus promoting control over practice. Believing that our staff nurses on the units, in the clinics, perioperative, and procedural areas are key clinical leaders, we have provided them with tools and education to identify issues where they are the experts. They are assisted in (1) carefully planning meeting agendas, (2) gathering and examining data, (3) including appropriate stakeholders in problem solving, and (4) facilitating consensus decision making. Identifying a fallback mechanism for decision making if consensus cannot be reached in the preplanned timeframe is important. Our direct care staff and their respective managers team together at the local (unit or clinic) level. Again, there are 2 cochairsvboth at the staff level, most often registered nurses. One nurse generally serves as the chairperson and the other as the cochair. This frames a mentoring-type arrangement, similar to professional organizations president and president-elect structure. The cochairs support one another and confer with the respective management team to plan agenda and strategize goals, typically focusing on issues within one or more of the following realms: (1) quality of patient or family care and satisfaction, (2) safety, (3) quality of work life, and (4) education for staff and/or patients and families. Most of the agenda items originate from the direct care staff. Our partnership and team approach is congruent with Kanter s model of organizational empowerment 1 that offers a framework for creating JONA Vol. 37, No. 12 December

3 meaningful work environments, and our experience is that it also develops and cultivates leadership at all levels in the organization. In the midst of a severe nursing shortage, 7,8 we focus particularly on frontline leaders in our hospitals and clinicsv nurse managers, assistant managers, charge nurses, staff educators, and staff nurses. Because these clinical leaders are supported and coached by administrators and other mentors, both mentors and mentored gain access to information and expertise. They put plans into action. We strive to assure they have resources and time to do their work, which fosters professional growth and learning. This in turn encourages further empowerment and commitment to the organization. Both accountability and ownership increase. Key indicators have increased steadily since 2003 in our staff satisfaction survey results. These include issues surrounding trust, control over nursing practice, group cohesion, effective communication, and involvement in decision making, among others. Strategies to Sustain the Culture Our recommitment to shared governance during the past few years employs strategies that echo Kanter s avenues of structural empowerment. We have focused on access to information with education, training, and multiple lines of communication. We provide specific support through coaching and networking, as well as confirmation of support for shared decision making in general from executive leadership. Access to resources includes convenient classes, literature, agenda and minute templates, private consultation, and facilitator assistance. There is ample opportunity for learning and growth. Leadership abilities thrive. The shared governance task force concluded that to invigorate shared decision making in the organization, particularly at the unit/clinic level, concentrated attention was needed. A director of shared governance implementation was hired to focus on this effort. A program coordinator was added to support logistics as well as to assist with system-wide agenda planning and meeting coordination. Another major accomplishment of the shared governance task force has been to bring our Nursing Bylaws back to the forefront. The Bylaws are thoroughly reviewed and revised by nurses at every level in the organization, resulting in a highly interactive Nursing Bylaws Convention every other year. Using the shared governance task force for guidance, the shared governance implementation staff facilitates training and educational activities for staff and managers learning how to organize and conduct productive meetings and how to start/ maintain shared governance mechanisms at the local level. To jump-start training, we sent more than 250 staff members to an outside workshop called The 4 Ps of Effective MeetingsVPurpose, People, Performance and Processes. 9 Currently, our own human resource department provides similar training. A critical piece to the education process was to develop a 4-hour workshop entitled Board Basics that contains an overview of shared governance and the basic ingredients to start and maintain local level decision making. This course begins a coaching relationship between the shared governance implementation staff and the workshop attendees. They go back to their units to apply what they learn in order to refine shared decision making in their clinical areas. Continued coaching is available. A monthly shared governance support group lends further assistance to these teams. Three of the most popular monthly support group sessions have been (1) evidence-based practice, (2) personality styles, and (3) panel discussionvwherein the panel experts are staff leaders. Most sessions offer contact hours. Additional workshops to address specific issues are available through human resources. Two examples are (1) Managing Workplace Negativity and (2) Building Trust. Skilled facilitators from our learning center department are also available for specific consultation. Concerted efforts have been required to encourage inpatient, procedural, and outpatient areas to initiate and sustain local boards. Many areas that already had a board needed to revamp. In several areas, much transformation has occurred. Because shared governance is a continuum, people need to be met where they are on their journey and coached to progress to the next point. A key mechanism has been developing a communication tree as well as a shared intranet portal to allow for networking and comparison of best practices and processes. Celebrating achievements and efforts through recognition has been motivating. The shared governance implementation staff personally attend as many local board meetings as possible, following up with debriefings. There was also much celebration of success witnessed as we prepared for our Magnet site visit. Recognition is part of our culture. Further acknowledgment of the value of this work and those making it successful occurs by inviting staff leaders to attend select Nursing Leadership Academy (The Advisory Board Company) workshops. Staff who attend the Academy with their management teams receive affirmation to 566 JONA Vol. 37, No. 12 December 2007

4 the partnership that is the centerpiece of our shared governance model. These opportunities also augment skill building and feelings of accountability. Three of these sessions well attended by staff leaders are (1) Negotiation Workshop: Maximizing Gains by Pursuing Shared Interests, (2) Managing Conflict: Bridging Individual Differences for Improved Performance, and (3) Strengthening Nurse-Physician RelationshipsVCultivating a Collaborative Clinical Network. 10 All implementation strategies meet a criterion for workplace empowerment. A strategy either enhances access to information, access to resources, support for the work, opportunity to develop, or a combination of these. In addition to making recommendations for implementation efforts, the shared governance task force actively engages in evaluation of implementation. This is done by conducting face-to-face interviews of unit and clinic board chairs and managers together every year. These data are analyzed along with staff satisfaction, group cohesion, control over practice, and various focus group data to identify opportunities for improvement. Other evaluation instruments are being investigated. Our executive leadership also is leading an aggressive journey to establish new service standards. This is being done by setting organizational pillar goals, measuring performance, adhering to a standard of professional and personal behavior, and building a working environment that stimulates staff to grow while acting on behalf of our patients and families to make a difference. The specific problem solving done at the unit level fits easily into the pillar format (people, service, quality, growth and finance). 11 These pillars provide a common language for all. With the availability of data on quality, patient satisfaction, and staff satisfaction, the shared governance structure provides forums for continuous improvement within each pillar. An effective shared governance structure is one method of laying the foundation to achieve the Forces of Magnetism as well. Thus, all organizational endeavors are synergistic and transparent rather than standing in separate silos. Implications Although new forecasts regarding the nursing shortage by 2020 are less severe than previously estimated (340,000 vs 800,000), this new forecast still constitutes a number 3 times larger than the peak of the registered nurse shortage in ,13 Nursing workforce literature recommends 7 key strategies to combat this problem, 2 of which are (1) fix problems associated with a negative workplace climate through promoting involvement in decision making and propagating collaborative relationships with physicians and management and (2) keep the long-term in mind by focusing on improving the workforce environment, to encourage registered nurses who enter the nursing workforce to stay and those who expect to retire in the near future to postpone. 7 The nurse manager plays a key role as chief retention officer, mentor, coach, and facilitative frontline leader. Retaining this valuable resource is put at risk by increasing nurse manager stress, particularly in acute care settings. 8 The work environment is critical. Administrators must endeavor to create supportive and empowering work environments for nurse managers and staff nurses alikevthe nursing shortage affects all nursing roles. Strengthening and aligning our precious human capital resources with partnership models is crucially important in recruitment and retention of qualified people into ever-changing and highly complex healthcare settings. Interdisciplinary and collaborative relationships are key strategies to defuse stress, spread out accountability, solve problems, and keep communication productive and open. Summary We should strive continuously to enhance our work environment. A study linking empowerment to magnet hospital characteristics found higher perceptions of autonomy and control over nursing practice in addition to positive nurse-physician relationships. 14 Strategies leading to these satisfiers will assist healthcare organizations to meet the demand for direct care nurses and the development of facilitative leaders needed to create a positive work environment. In the spirit of continuous improvement and professionalism, healthcare organizations must never stop seeking ways to engender a satisfying and fulfilling workplace. Acknowledgments The authors thank Nancy Wells, DNSc, RN, FAAN, Director of Nursing Research, for help in preparing this article; Robin Steaban, MSN, RN, Administrator Cardiovascular Services, for leadership in shared governance over many years; Marilyn Dubree, MSN, RN, Chief Nursing Officer, for supporting an environment within which professional empowerment and leadership development can flourish; and Vanderbilt University Medical Center for caring about a positive work environment. JONA Vol. 37, No. 12 December

5 References 1. Kanter RM. Men and Women of the Corporation. 2nd ed. New York, NY: Basic Books; Laschinger HKS, Finegan J. Using empowerment to build trust and respect in the workplace: a strategy for addressing the nursing shortage. Nurs Econ. 2005;23(1): Laschinger HKS, Havens DS. Staff nurse work empowerment and perceived control over nursing practice: conditions for work effectiveness. J Nurs Adm. 1996;26(9): Laschinger HKS, Finegan J, Shamian J. The impact of workplace empowerment, organizational trust on staff nurses work satisfaction and organizational commitment. Health Care Manage Rev. 2001;26(3): Laschinger HKS, Wong C, McMahon L, Kaufmann C. Leader behavior impact on staff nurse empowerment, job tension, and work effectiveness. JNursAdm. 1999;29(5): Interaction Institute for Social Change. Facilitative Leadership A : Tapping the Power of Participation. Cambridge, MA: Interactive Associates, LLC; org/. Accessed April 9, Buerhaus P, Donelan K, Ulrich B, Norman L, Dittus R. State of the registered nurse workforce in the United States. Nurs Econ. 2006;24(1): Shirey M. Stress and coping in nurse managers: two decades of research. Nurs Econ. 2006;24(4): , The Institute of Cultural Affairs. The 4P`s of Effective Meetings. Nashville, TN: Management Solutions Group, LLC; Accessed April 9, The Advisory Board Company. Nursing Leadership Academy. Washington, DC; Ongoing access Studer Q. Hardwiring Excellence: Purpose, Worthwhile Work, Making a Difference. 1st ed. Gulf Breeze, FL: Fire Starter Publishing; US Depart of Health and Human Services. Projected supply, demand, and shortages of registered nurses: Washington, DC: US Depart of Health and Human Services; Auerbach D, Buerhaus P, Staiger D. Better late than never: workforce supply implications of entry into nursing. Health Aff. 2007;26(1): Laschinger HKS, Almost J, Tuer-Hodes D. Workplace empowerment and magnet hospital characteristics: making the link. 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