Embracing a Nursing Shared Decision Making Model

Embracing a Nursing Shared Decision Making Model

The Department of Nursing in Mayo Health System s western region is journeying from a traditional management model to a Shared Decision Making Model. Shared decision making is the foundation that supports our vision of being a premier nursing organization, building upon a culture that is patient centered, caring and engaged in nursing inquiry. This booklet details our Shared Decision Making Model and how we are making our vision a reality. What is a Shared Decision Making Model? A Shared Decision Making Model is a collaborative governance structure that gives professionals a voice regarding issues that affect their practice. It is also known as Shared Governance. In Mayo Health System s western region, we are incorporating the principles of shared decision making into our nursing administrative model. These principles include: Staff nurses must have an active role in making decisions, forming policies and/or controlling actions and behaviors (Anderson, 1990). Sharing power promotes interdependence and cooperation (Shidler, Pencak & McFolling, 1989). Professional workers deserve an accountability-based governance system (Porter-O Grady, 1987). The environment must promote autonomous staff nurse practice (Pinkerton, 1988). What does shared decision making look like? Shared decision making encourages and expects participation by nurses at all levels of the organization. It promotes working conditions wherein individuals work to their fullest potential. When shared decision making is present: Management moves from directing and controlling to coaching, guiding, questioning and facilitating. Centralized or decentralized responsibility is replaced with mutual shouldering of responsibility. Tight, hierarchical reporting relationships give way to a loose interactive structure. Respect, cooperation and collegiality replace competition and conflict.

Communication becomes multidirectional, open and free-flowing instead of only up or down. Purpose is shared, understood, and accepted by all. Problems are discussed and eliminated frustration and burnout are replaced by challenge, enthusiasm, and progress. Commitment is instilled in members: commitment to each other and to the quality of work that results from their efforts. (Taken from: Neis, M.E. and Kingdon, R.T. (1990). Leadership in Transition: A Practical Guide to Shared Governance. (1st Ed.). Schaumberg, IL: Nova I, Ltd.) How does shared decision making differ from a traditional hierarchy? Nursing leaders and staff nurses function differently under a Shared Decision Making Model. This table contrasts expectations for each group under both models. Staff Expectations Leader Expectations Traditional Hierarchy Follow Directions. Abide by the rules. Follow the chain of command. Do the job, don t complain. Don t make a mistake. Run a tight ship. Keep the boss informed. Punish mistakes; deny errors. Set your own style. Follow the chain of command. You re the boss, you decide. Keep the troops in line. The boss is always right. Don t rock the boat. Shared Decision Making Ask the questions, make a suggestion. Days of free complaining and blame-placing are over. Participate in active problem solving. Use effective communication. Take responsibility for the environment and for the quality of products/services. Talk to those necessary to get the job done. Embrace errors. Give up control, be inclusive in style. Encourage questioning, invite challenges. Show the way by being an example for others to follow. Find out for yourself!

How do nurses benefit from a shared decision making process? Nurses define, delineate, create, approve and evaluate all nursingpractice activities. Nurses assume full responsibility and accountability for all activities related to nursing practice. Practice related issues are dealt with by practicing nurses, rather than by managers. Nurses move from subservient to autonomous roles as they exercise authority over decisions related to their practice. Nurses experience more control over their working environment and the professional practice of nursing. Staff nurses emerge as leaders as they assume responsibility for their practice. The power base for nursing practice shifts to the hands of the practicing nurse, who is the major provider of care in the hospital setting. Nurses attitudes towards the work environment improve. Nurses experience an improved climate for innovation and change. Nurses perceive themselves as more satisfied with their jobs. Nursing clinical expertise is recognized and valued in a continually changing healthcare system. Physicians become more aware of the decision-making skills of the nurses and recognize the positive impact nurses have on patient care delivery and outcomes. What types of decisions does shared decision making allow nurses to make? Within the Department of Nursing in Mayo Health System s western region, there are two domains of decision making: managerial and professional. Managerial decisions remain the responsibility of administrative leaders. Professional practice decisions become the responsibility of staff nurses and allied health care professionals. The following table lists examples of decisions that lie within each domain:

Management Providing a new program Nursing strategic planning Disciplinary action and process Personnel issues Budget and resources Design of strategies and budgetary processes Professional Practice Nursing practice standards Policies and procedures Continuous improvement Peer review Patient care Professional development Priorities for staff development There are times when both domains are involved in the decision making process. This diagram illustrates the continuum of decision making from the managerial domain to the professional practice domain. COMMAND CONSULTATIVE CONSENSUS HIGH MANAGEMENT (Individual) Acceptance Time PROFESSIONAL PRACTICE (Group) LOW Decisions made solely by management are often command decisions. Command decisions usually involve very few individuals, take the least amount of time and often have low acceptance. On the other side of the continuum is consensus. Consensus involves all individuals and takes the greatest amount of time, but is also associated with greatest amount of acceptance. There will always be some command decisions within any organization, but consensus is the preferred method of decision making under a Shared Decision Making Model. How does shared decision making work? The foundation of the Shared Decision Making Model are the councils, committees and meetings which allow nurses to engage in making decisions that affect their practice. Staff nurses comprise 60% or more of the membership within the councils, committees or meetings. This diagram illustrates flow of information between the various councils,

committees and meetings in the Shared Decision Making Model for the Department of Nursing in Mayo Health System s western region. Leadership Inpatient Charge Nurse Committee Data & Documentation Committee Skin Quality Committee & Safety Falls Committee Restraints Committee Coordinating Division Meetings Professional Recruitment Practice & & Retention Education Staff Meetings Inpatient Ambulatory Charge Ambulatory Manager Nurse Committee Manager Meeting Policy & Procedure Department of Nursing Shared Decision Making Diagram for Mayo Health System s western region Unit s Information Flow Reporting Relationship 8.2010 Group Structure Group Overview Defined Groups s s are the core workgroups that comprise our Shared Decision Making Model. These ongoing groups have diverse representation and support advancement of organizational and departmental goals. Our model includes seven core councils: Nursing Coordinating Nursing Leadership Nursing Policy and Procedure Nursing Professional Practice and Education Nursing Quality and Safety Nursing Recruitment and Retention Ambulatory Nurse Manager Unit s

Group Structure Group Overview Defined Groups Committees Committees are ongoing groups sanctioned by a council. They have a focused scope of work with goals that are measurable and link directly to the purpose and objectives of the sponsoring council. Committees send recommendations to councils for action. Like councils, committees support shared decision making with optimal participation while operating efficiently. Data & Documentation Committee Falls Committee Restraints Committee Skin Committee Inpatient Charge Nurse Committee Ambulatory Charge Nurse Committee Meetings Meetings are organized by leadership to discuss information from council and committees, or other pertinent topics. Meetings provide a venue for clarifying information and presenting possible questions or recommendations that can be taken back to councils or committees for further analysis and discussion. Charge Nurse Meeting Director/Patient Care Manager/ Administrative Supervisor Meetings Division Meetings Inpatient Nurse Manager Meetings Staff Meetings Who can serve on a council or committee? Nurses in good standing (with no written corrective action in the past six months) who have had six months experience working in their area of nursing and are employed at 0.6 FTE or greater, are eligible to participate on councils and committees. Ideal candidates embrace a global view of nursing practice issues, and are willing and able to meet professional responsibilities of the council. Because each council is comprised of no more than 12 members, there is a nomination and election process for selection of members. Members serve for a two year term, and are expected to attend 75 percent of the meetings. Additional responsibilities include

representing their practice area by engaging and gathering staff input and communicating council information back to staff. For more information on the Shared Decision Making Model for the Department of Nursing in Mayo Health System s western region, go to the Nursing website on ISJWeb or see your Nurse Manager, Nurse Director or the Chief Nursing Officer. Together we can achieve excellence through shared decision making. Bibliography A complete bibliography of references used for developing this Shared Decision Making Model may be found on our website: www.isj-mhs.org. From the menus on the left, select Nursing, then About Us, and finally, Decision Making.

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1025 Marsh Street, P.O. Box 8673 Mankato, MN 56002-8673 507-385-2692, 507-385-5659 or 1-800-327-3721, ext. 2620 www.isj-mhs.org 09/10