Nursing Care Models Paper:
The purpose of this assignment is to identify nursing care models utilized in today?s various health care settings and enhance your knowledge of how models impact the management of care and may influence delegation. You will assess the effectiveness of models and determine how you would collaborate with a nurse leader to identify opportunities for improvement to ensure quality, safety and staff satisfaction.
Completion of this assignment enables the student to meet the following course outcomes.
CO#1: Apply leadership concepts, skills, and decision making in the provision of high quality nursing care, healthcare team management, and the oversight and accountability for care delivery in a variety of settings. (PO #2)
CO#2: Implement patient safety and quality improvement initiatives within the context of the interprofessional team through communication and relationship building. (PO #3)
CO#3: Participate in the development and implementation of imaginative and creative strategies to enable systems to change. (PO #7)
CO#6: Develop a personal awareness of complex organizational systems and integrate values and beliefs with organizational mission. (PO #7)
CO#7: Apply leadership concepts in the development and initiation of effective plans for the microsystems and/or system-wide practice improvements that will improve the quality of healthcare delivery. (PO #2, and #3)
CO#8: Apply concepts of quality and safety using structure, process, and outcome measures to identify clinical questions as the beginning process of changing current practice. (PO#8)
This assignment is worth 200 points.
1. Read your text, Finkelman (2012), pp- 118- 127.
2. Observe staff in delivery of nursing care provided. Practice settings may vary depending on availability.
3. Identify the model of nursing care that you observed. Be specific about what you observed, who was doing what, when, how and what led you to identify the particular model.
4. Write a 5-7 page paper that includes the following:
5. Review and summarize two scholarly resources (not including your text) related to the nursing care model you observed in the practice setting.
6. Review and summarize two scholarly resources (not including your text) related to a nursing care model that is different from the one you observed in the practice setting.
7. Discuss your observations about how the current nursing care model is being implemented. Be specific.
8. Recommend a different nursing care model that could be implemented to improve quality of nursing care, safety and staff satisfaction. Be specific.
9. Provide a summary/conclusion about this experience/assignment and what you learned about nursing care models.
10. Write your paper using APA format.
GRADING CRITERIA: NURSING CARE MODELS PAPER
Category Points % Description
Identify Nursing Care Model in practice including specifics about who, what when, where, etc. 60 30% Identifies Nursing Care Model for delivery of nursing care. Provides specifics.
Besides Finkelman, locate scholarly resources related to Nursing Care Models 40 20% In addition to Finkelman, locates four scholarly resources related to Nursing Care Models. Summarizes all resources in body of paper.
Implementation and Recommendations 60 30% Describe implementation of current Nursing Care Model and recommend a different model that could be utilized to improve quality of nursing care, safety and staff satisfaction.
Conclusion/ summary 20 10% Summarize what you learned about this experience including new knowledge about nursing care models.
Clarity of writing 20 10% Content is organized, logical, and with correct grammar, punctuation, spelling, and sentence structure are correct. APA formatting is apparent and CCN template is utilized. References are properly cited within the paper; reference page includes all citations; proper title page and introduction are present and evidence of spell and grammar check is obvious.
Finkelman text reading Pages 118-127
PROFESSIONAL NURSING PRACTICE WITHIN NURSING CARE MODELS
The American Nurses Association (2004) defines nursing as ?the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations? (p. 7). The American Organization of Nurse Executives (AONE) emphasizes the following with patient population as the central core (2005).
? The core of nursing is knowledge and caring. (evidence-based practice and patient-centered care)
? Care is user-based. (patient-centered care)
? Knowledge is access-based. (evidence-based practice)
? Knowledge is synthesized. (evidence-based practice; informatics; quality improvement)
? Relationships of care presence-virtual. (patient-centered care)
? Managing the journey (interprofessional teams)
The items in italic describe how each of the AONE elements relate to the five IOM core competencies. These are all interrelated. Also all of these elements have been discussed in earlier chapters or will be discussed in later chapters as they are critical aspects of leadership and management. Intertwined within these critical elements is the recognition of the importance of autonomy, responsibility, delegation, and accountability.
?Autonomy in clinical decision making occurs whenever a nurse makes an independent judgment about the presence of a clinical issue and then provides the resolution to nursing care? (Ritter-Teitel, 2002, p. 32). Autonomy requires competence and skills that focus on the nurse?patient relationship. It also means that there needs to be an organized assessment method to determine patient care needs and reassigning staff. Nurses also have the right to consult with others as professionals when they provide or manage care. Autonomy, control, and decision making are related. ?Professional practice implies control over the terms of the work but also control over its content and regulation of its standards? (Ritter-Teitel, 2002, p. 33). Nurses who feel that they have autonomy know that they have the right to make decisions in their daily practice and also actively participate in developing organizational policy and change. Staff autonomy, however, does not work in organizations in which leaders are authoritarian and when centralized decision making and control are key characteristics of the organization. This situation will quickly lead to conflict. In addition, the work environment must be conducive to collaboration with physicians and all relevant staff, as is discussed in Chapter 12. ?Responsibility refers to being entrusted with a particular function? (Ritter-Teitel, 2002, p. 34). A nursing practice model that does not address responsibility will not be effective. Along with this is the need to clearly recognize the importance of delegation. ?Delegation involves transferring responsibility for the performance of the task from one person to another? (Ritter-Teitel, 2002, p. 34). Delegation is discussed in more detail in Chapter 14. Accountability is a term that is typically found in job descriptions and descriptions of organizational structure. In nursing it is particularly important to recognize that ?accountability is the acceptance of responsibility for the outcomes of care? (Ritter-Teitel, 2002, p. 34). Nurses need to know that when they provide patient care their work has relevance?it must reach outcomes. Magnet hospitals are discussed in Chapter 6 as examples of organizations that exemplify these characteristics.
The AONE elements and these characteristics, such as accountability, need to be considered when nursing practice models are assessed. Models of care are developed to support or enhance professional practice, and by considering these elements and characteristics the models will be more effective. Within a health care organization, how do nurses provide nursing care? What is a model of care? Are these elements found in the model? ?A model of care is a configuration of nursing practice or pattern of delivery? (Ritter-Teitel, 2002, p. 35). Models might also be called nursing or patient care delivery systems. These models have undergone major changes over the last several decades. Nursing practice models have been used to implement resource-intensive strategies with the goal of decreasing expenses and using staff more effectively. These practice models establish organizational frameworks that provide nursing staff opportunities to become more committed to their practice and to be more involved in decision making (Upenieks, 2000, p. 330). A review of multiple nursing care models (Beattle, 2009) indicates that many models have common themes:
? Elevating the role of nurses and transitioning from caregivers to ?care integrators?
? Taking a team approach to interprofessional care
? Bridging the continuum of care outside of the primary care facility
? Defining the home as a setting of care
? Targeting high users of health care, especially older adults
? Sharpening focus on the patient, including an active engagement of the patient and his or her family in care planning and delivery, and a greater responsiveness to patient wants and needs
? Leveraging technology
? Improving satisfaction, quality, and coast
Others have identified the following elements that are still relevant today (Brennan, Anthony, Jones, & Kahana, 1998): continuity of care, participation in management, collaboration, leadership, learning environment, nurse?s role, staffing communication, specialization, orientation of temporary staff, and team commitment. O?Rourke (2006) believes that building the professional role is important and describes a professional practice model with a professional role development emphasizing self-direction and decision making, evidence-based practice, role-based transfer of knowledge, and role-based provision of care. See Chapter Media Links for access to website describing the O?Rourke model.
Nursing models?provide an infrastructure that decreases variation among nurses, the interventions they will choose, and, ultimately, patient outcomes. Conceptual frameworks also differentiate forward thinking organizations from those where nursing has less of a voice? (Kerfoot, et al., 2006, p. 20). Models help to identify and describe nursing care. The IOM emphasis on the five core competencies could be used for a model and as newer models are discussed later it is easy to see how these five competencies are the key elements of health care delivery. Kimball and Joynt (2007) identify key factors driving innovation in health care delivery. These factors are described in Figure 4-2.
HISTORICAL PERSPECTIVE ON NURSING MODELS
The following is a description of common models, some of which have undergone many changes over the years or are not used anymore, but they have had an impact on newer models. In addition, how models are implemented in an organization can be highly variable.
TOTAL PATIENT CARE/CASE METHOD
In this model, which is the oldest, the registered nurse is responsible for all of the care provided to a patient for a shift. A major disadvantage of this model is the lack of consistency and coordinated care when care is provided in 8-hour segments. This type of care is rarely provided today, except among student nurses who are assigned to
FIGURE 4-2 WHAT IS DRIVING INNOVATION?
Source: Kimball, B. & Joynt, J. (2007). The quest for new innovative care delivery models. JONA, 37(9), 392?398. Reprinted with permission.
provide all of the care for a patient during the hours that they are in clinical. Even in this case, the students frequently do not provide all of the care as they may not be qualified to do this and a staff nurse maintains overall responsibility for the care. Home health agencies use a form of this model when nurses are assigned patients and provide all the required home care; however, even this has been adapted as more home care is provided by a team. An RN may coordinate the care and provide professional nursing services, but a home care aide may provide most of the direct care and other providers such as a physical therapist, dietician, and social worker may be required for specialty care.
The model of functional nursing is a task-oriented approach, focusing on jobs to be done. When it was more commonly used, it was thought to be more efficient. The nurse in charge assigned the tasks (e.g., one nurse may administer medications for all patients on a unit; an aide may take vital signs for all patients). A disadvantage of this model is the risk of fragmented care. In addition, this type of model also leads to greater staff dissatisfaction with staff feeling they are just grinding out tasks. Individualized care may also be compromised when patient care is provided by different staff members who may or may not be aware of other needs and the care provided by others. This model is not used much now. It can be found in some long-term care facilities and in some behavioral/psychiatric inpatient services, although in a modified form. In the latter situation a registered nurse may be assigned the task of medication administration for the unit, and psychiatric support staff may be assigned such tasks as vital signs and checks of all patients. In this situation, RNs would still be assigned to individual patients to coordinate their care.
Team nursing, developed after World War II when there was a severe nursing shortage as well as major changes in medical technology, replaced functional nursing. A nursing team consists of an RN, licensed practical nurses (LPNs), and nurse aides. This team of two or three staff provides total care for a group of patients during an 8- or 12-hour shift. The RN team leader coordinates this care. In this model the RN has a high level of autonomy and assumes the centralized decision-making authority. Although the past approach to team nursing was thought to use decentralized decision making with decisions made closer to the patient, there actually was limited team member collaboration. In addition, these teams tended to communicate only among themselves and not as well with physicians. The team concept or model also focused on tasks rather than patient care as a whole. More current versions of the team model are different from this earlier type. Currently, the team model has been changed to meet changes in organizations and leadership corresponding to the needs for better consistency and continuity of care, as well as collaboration and coordination.
In the late 1970s care became more complex, and nurses were dissatisfied with team nursing. In the primary nursing model the primary nurse, who can only be an RN, provides direct care for the patient and the family; an associate nurse provides care following the care plan developed by the primary nurse when the primary nurse is not working and assists when the primary nurse is working. The primary nurse needs to be knowledgeable about assigned patients and must maintain a high level of clinical autonomy. When primary nursing was first used and well-accepted it was easier to substitute RNs for other health care providers as cost was not as much of a focus as it is today. When the nursing shortage began to reoccur and salaries increased, implementing primary nursing became more difficult, and health care cost moved to the top of the concerns. There was, however, no research data to support that primary nursing was more expensive than team nursing, but many hospitals nonetheless felt it was (Gardner, 1991; Gardner & Tilbury, 1991; Glandon, Colbert, & Thomason, 1989; Shukla, 1983). Primary nursing is often viewed as a model in which the primary nurse has to do everything, limiting collaborative or team effort, although it does not have to be implemented in this way.
Second-generation primary nursing clarifies some of the issues about this practice model. One of the critical problems with primary nursing was whether or not it required an all-RN staff, which was thought to increase staff costs. The second-generation view of primary nursing noted that the mix of staff is more important than having an all-RN staff. Another concern with primary nursing was a need to develop a clear definition of 24-hour accountability, which was interpreted by some as 24-hour availability. This, of course, is not a reasonable approach, and it really does not apply to primary nursing. When the primary nurse is not working, the associate nurse provides the care. Primary nursing is a responsibility relationship between the nurse and the patient. The primary nurse is not the only caregiver but does have responsibility for planning the care and ensuring that care outcomes are met. Only registered nurses can be primary nurses. This role and the model require RNs who are competent and possess leadership skills. Primary nursing is not used as much today.
CARE AND SERVICE TEAM MODELS
In the 1980s, care and service team models began to replace primary nursing. These models are implemented differently in different hospitals, as is true of most of the models. Key elements of these models are empowered staff, interprofessional collaboration, skilled workers, and a case management approach to patient care?all elements related to the more current views of leadership and management (Finkelman, 2011). Care and service teams introduced the different categories of assistive personnel (for example, multiskilled workers, nurse extenders, and UAP). There has been some disagreement as to whether these new staff member roles were complementary or involved substitution of professional nursing care.
Complementary modelsbegan in 1988 by using nurse extenders, such as a unit assistant, who would be responsible for environmental functions. The nurse would then have more time for direct patient care. Does this reduce costs? Certainly, when nurse positions are changed to nurse extender positions there is some cost reduction; however, some hospitals found that overtime, sick time, and on-call costs rose, particularly with nurse extender staff (Powers, Dickey, & Ford, 1990). Another example is Manthey?s (1989) partners-in-practice. Technical assistants signed a partnership agreement to work with an experienced RN. Reduction in costs was initially seen with this model because each partnership could care for the same number of patients as two RNs. Staffing costs, however, continued to increase. Complementary models are not used as much today and have been replaced by substitution models in health care organizations. Substitution models tend to use multiskilled technicians to perform select nursing activities. The RNs supervise these activities.
Another approach is cross-training. This involves training staff to work in different specialty areas or to perform different tasks. For example, a respiratory therapist may be trained not only to perform typical respiratory therapist tasks but also phlebotomy and basic nursing care. This offers much more flexibility in that staff can fulfill many different needs. They can then be used as staffing adjustments are needed for changes in patient census or acuity. It is critical that this cross-training meet patient needs so that staff will be able to deliver quality, safe care and not feel undue stress while delivering the care. It is also important that state practice act requirements are met, and this is not always easy to accomplish. It requires education staff to provide support, ongoing educational training, and documentation of competencies, as well as management staff who understands which staff members are qualified to move from area to area. Hospitals and other health care organizations are trying to find the best methods for using substitution without compromising quality and safety and yet control costs. As demands change, different models will be required, and nursing leadership to develop these models will be critical.
As with earlier team models, the RN must spend time coordinating care and the work. The focus of the team is on patient-centered care as opposed to the nurse?patient relationship. The Case Management Society of America (CMSA) defines case management as ?a collaborative process of assessment planning, facilitation and advocacy for options and services to meet an individual?s health needs through communication and available resources to promote quality cost-effective outcomes? (2002, p. 1). Case management is based on the assumption that patients with complex health problems, catastrophic health situations, and high cost medical conditions need assistance in using the health care system effectively and a case manager can help patients with these needs (Finkelman, 2011). Case managers may also work with the teams to achieve outcomes, which increases shared accountability. Case management can be viewed as a nursing model when the case manager is a nurse; however, in some organizations nurses are not used as case managers but rather other health care professionals such as social workers are the case managers. ?Case management is not a profession but rather a collaborative and trans-disciplinary practice? (Commission for Case Management Certification, 2009, p. 1). Several health care professional organizations and experts have defined case management; however, there clearly is no universally accepted definition for case management. Case management is used in many different types of settings, and the setting also affects the definition (Finkelman, 2010).
CARE MANAGEMENT MODEL
The care management model focuses on the needs of the integrated delivery system. It has many similarities to case management, in that it includes planning, assessment, and coordination of health services. The patient focus, however, is population-based instead of based on an individual patient. The population might be people who live in a specific geographic area, members of a health insurance plan, or could be a specific group with similarities, such as patients with diabetes. The goal is to integrate a continuum of clinical services. Care management is not only concerned with medical care but also health promotion and disease prevention, costs, and use of resources. Case management is often used within the care management model. Typical tools used to facilitate care management are clinical pathways, disease management programs, and benchmarking.
NEWER NURSING MODELS
INTERDISCIPLINARY PRACTICE MODEL
The interdisciplinary or interprofessional practice model is emphasized in the IOM reports on quality improvement by identifying the importance of all health professions meeting the interdisciplinary or interprofessional competency emphasizing the need to work in interprofessional teams ?to cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous and reliable? (2003, p. 4). These teams include providers from different health care professions and occupations designed to meet the required patient needs. With increasing complex patient care needs this model is better able to address needs and to effectively use a mix of expertise and knowledge to reach patient outcomes. Patient-centered care is the focus. The advantages of using interprofessional teams are as follows (Finkelman & Kenner, 2010, p. 337):
? Decreased fragmentation in a complex care system
? Effective use of multiple expertise (e.g., medicine, nursing, pharmacy, allied health, social work, and so on)
? Decreased utilization of repetitive or duplicate services
? Increased creative or innovative solutions to complex problems
? Increased learning for team members about different roles and responsibilities, communication and coordination, and how to better plan care
? Provides motivation and increased self-esteem in team and individual performance
? Greater sharing of responsibility
? Empowers members to speak up
SYNERGY MODEL OF PATIENT CARE?
This model of care was developed by the American Association of Critical Care Nurses, but it has been applied in all types of nursing units. ?Synergy results when the needs and characteristics of a patient, clinical unit, or system are matched with a nurse?s competencies? (American Association of Critical Care Nurses, 2009). Patient characteristics incorporated into this model are as follows (American Association of Critical Care Nurses, 2009):
? Resiliency: the capacity to return to a restorative level of functioning using compensatory/coping mechanisms; the ability to bounce back quickly after an insult
? Vulnerability: susceptibility to actual or potential stressors that may adversely affect patient outcomes
? Stability: the ability to maintain a steady-state equilibrium
? Complexity: the intricate entanglement of two or more systems (e.g., body, family, therapies)
? Resource availability: extent of resources (e.g., technical, fiscal, personal, psychological, and social) the patient/family/community brings to the situation
? Participation in care: extent to which patient/family engages in aspects of care
? Participation in decision making: extent to which patient/family engages in decision making
? Predictability: a characteristic that allows one to expect a certain course of events or course of illness
The Synergy model ties the above patient characteristics with the following nurse competencies (American Association of Critical Care Nurses, 2009).
? Clinical judgment: clinical reasoning, which includes clinical decision making, critical thinking, and a global grasp of the situation, coupled with nursing skills acquired through a process of integrating formal and informal experiential knowledge and evidence-based guidelines.
? Advocacy and moral agency: working on another?s behalf and representing the concerns of the patient/family and nursing staff; serving as a moral agent in identifying and helping to resolve ethical and clinical concerns within and outside the clinical setting.
? Caring practices: nursing activities that create a compassionate, supportive, and therapeutic environment for patients and staff, with the aim of promoting comfort and healing and preventing unnecessary suffering. Includes, but is not limited to, vigilance, engagement, and responsiveness of caregivers, including family and health care personnel.
? Collaboration: working with others (e.g., patients, families, health care providers) in a way that promotes/encourages each person?s contributions toward achieving optimal/realistic patient/family goals. Involves intra- and interprofessional work with colleagues and community.
? Systems thinking: body of knowledge and tools that allow the nurse to manage whatever environmental and system resources exist for the patient/family and staff, within or across health care and non?health care systems.
? Response to diversity: the sensitivity to recognize, appreciate, and incorporate differences into the provision of care. Differences may include, but are not limited to, cultural differences, spiritual beliefs, gender, race, ethnicity, lifestyle, socioeconomic status, age, and values.
? Facilitation of learning: the ability to facilitate learning for patients/families, nursing staff, other members of the health care team, and community. Includes both formal and informal facilitation of learning.
? Clinical inquiry (innovator/evaluator): the ongoing process of questioning and evaluating practice and providing informed practice. Creating practice changes through research utilization and experiential learning.
PRIMARY CARE TEAM
The Primary Care Team (PCT) is a model that emphasizes differentiated nursing practice from a team perspective (Kimball & Joynt, 2007). The team includes an RN care manager, RN or LPN/LVN provider, and clinical assistant. The patient is actively involved in the care process. The team principles are as follows (Kimball & Joynt, 2007. p. 394):
? Every patient deserves an experienced RN.
? Every novice nurse deserves mentoring from an experienced RN.
? Every patient deserves the opportunity to participate in planning of his or her care.
? Every team member is committed to meet the needs of every patient assigned to the team.
? Each PCT member functions within his or her defined scope of practice/experience.
? Work intensity decreases with improved work distribution processes and team support.
? The model of nursing care delivery is an important element in patient safety and patient, staff, and physician satisfaction.
COLLABORATIVE PATIENT CARE MANAGEMENT MODEL
The Collaborative Patient Care Management Model is an interprofessional, population-based case management model (Kimball & Joynt, 2007). The model focuses on high risk, high volume, and high cost populations. The team is co-coordinated by a physician and an RN patient care coordinator. The RN leads rounds, and there is an interprofessional plan. This model has been used in acute care and outpatient settings across the continuum of care services.
TRANSITIONAL CARE MODEL
This model focuses on providing ?comprehensive in-hospital planning, care coordination, and home follow-up for high-risk elders? (Kimball & Joynt, 2007, p. 395). Nurse practitioners lead this model to ensure that the elders receive the care that they need, including post-hospitalization. The model has had a positive impact on decreasing time between readmissions, number of readmissions, and total health care costs. With the increasing number of elders this type of model will become more important.
Patient Navigation is a model that has primarily focused on patients with cancer who are at risk for poor cancer outcomes though other types of patients populations have also benefited from patient navigation (Wells et al., 2008). Clinical nurse leaders often hold the position of nurse navigator. Patient navigation focuses on decreasing barriers to better ensure that patients get the care they need when they need it (Finkelman, 2011). This mode is ?an intervention designed to reduce health disparities by addressing specific barriers to obtaining timely, quality health care? (Wells et al., 2008, p. 2010).
TRANSFORMATIONAL MODEL FOR PROFESSIONAL PRACTICE
This model integrates patient care services (Beckman Institute for Innovation in Patient Care, 1998 as cited in Wolf, Hayden, & Bradle, 2004). The model has four components: (1) professional practice: assessment and activation of professional practice relationships, and support with emphasis on transformational leadership, care delivery system, professional growth, and collaborative practice; (2) the process component: engagement in purposeful and deliberate critical thinking, negotiation, and decision-making; (3) the primary outcome component: reach targeted outcomes (quality improvement, patient satisfaction, caregiver satisfaction); and (4) the strategic outcome component: consumer, organizational, professional health).
THE QUALITY-CARING MODEL?
This model emphasizes caring and evidence-based practice with an emphasis on structure-process-outcomes as dimensions of quality care (Duffy & Hoskins, 2003). It addresses concerns about the need to build relationships with patients and families?cooperative, collaborative relationships. This is described as nursing?s work rather than a focus on a task oriented biomedical model.
Nursing care delivery models have changed over the years due to economic factors, staffing shortages or excesses, philosophy and goals, nursing research, tasks that need to be accomplished, technology, information management, scientific advancements, and new leadership and organization theories and styles. Some models have disappeared (for example, functional nursing). Another example of a model that is used less often is primary nursing, which was popular in many areas of the country, but is not used as much now, primarily due to costs and the RN shortage. The total patient care or case method, although rarely used, may still be used in critical care settings and home care, although even here there is a movement toward interprofessional care. Why have the changes occurred? Some nursing care can be done by others more cost effectively and still be safe, quality care, and staff are available to do these tasks, such as LPNs/LVNs or UAP. Typically, a hospital will use a combination of models.
CASE STUDY DOES A NURSING MODEL MAKE A DIFFERENCE?
As Director of Staff Development in a large university hospital, the Chief Nurse Executive (CNE) has met with you to discuss orientation for student nurses and faculty. The CNE is concerned that students and faculty do not understand the hospital?s new nursing model, Synergy model of patient care?. She tells you it is your job to correct this problem. You leave the meeting overwhelmed. This seems like a big responsibility to you. The hospital has many nursing students from three schools of nursing that use its services for practicum. All have to attend a 4-hour orientation to the hospital, which is already overburdened with content. The units have also been struggling with applying the model since it was initiated 6 months ago.
1. Why is it important for the students and faculty to understand the model?
2. How does the nursing model relate to the organization?s theory or approach?
3. How would you describe this model? Consider methods and examples.
4. Develop a plan that you will submit to the CNE explaining how you will address this problem. Who might you include in developing the plan and in implementing it?
?Governance, or self-regulation, has long been recognized as a privilege given to professions that earn the public trust by demonstrating accountability for their specialized practices? (Maas & Specht, 2001, p. 318). How does this relate to shared governance? As a nursing management form, shared governance emphasizes nurses? roles and responsibilities in decision making (Anthony, 2004; Hess, 2004). It thus increases each nurse?s influence over the organization, empowering staff and is based on six dimensions of governance.
1. Control over professional practice
2. Influence over organizational resources that support practice
3. Formal authority granted by the organization
4. Committee structures that allow participation in decision making
5. Access to information about the organization
6. Ability to set goals and negotiate conflict
Shared governance can be viewed as a management philosophy, a professional practice model, and an accountability model that focuses on staff involvement in decision making, particularly in decisions that affect their practice. In doing this the model provides staff with autonomy and control over implementation of their practice?legitimizing control over their own practice. Nurses in these organizations usually feel less powerless and are more efficient and accountable.
A critical factor in shared governance is that accountability and responsibility are found in the same person. Accountability should rest in the person who is most likely to be the most effective person to complete the function. For individual staff to be accountable and responsible for a function or task, staff must also have the authority to make sure that the right decisions are made. ?Within the professional context, then, the statement that the professional is accountable for his or her practice has meaning only when the necessary authority, which is part of that accountability, is transferred to the individual who assures compliance and who is capable of taking corrective action in the absence of compliance? (Porter-O?Grady & Finnigan, 1984, p. 80).
Shared governance is also a surrogate term for collaboration. ?It is an organizational arrangement with a highly participatory staff empowered to function cooperatively with both management and colleagues, and leadership that empowers staff. The organization can be referred to as a learning organization? (Sullivan, 1998, p. 471). Transformational Leadership enhances shared governance. As was discussed in Chapter 1, an important element of leadership is self-awareness, and it is important in shared governance. In this type of organizational arrangement staff members feel committed to the organization and consider themselves to be partners in meeting the goals of the organization. Staff members should not feel that they are working alone, but rather working in teams to meet specific goals (Hess, 2004).
In shared governance nurse managers typically are not directly involved in daily direct patient care, although there are some managers who are still involved in direct care. The typical responsibilities of the nurse manager are staffing, program evaluation, personnel evaluation, coordination, allocation of resources, financial activities, and long-range planning discussed in Chapter 1. If patient care outcomes are not met, it is the responsibility of the nurse providing the care to address this issue. The nurse manager may become involved, but it is the direct care provider who should take the lead. Clinical practice is the responsibility of the practitioners. When clinical problems occur, the nurse who provides direct care must be the one to solve these problems, working with the care team. The main factor in shared governance is that decision making is spread over a larger number of staff and is decentralized. Nurses are accountable for their practice. Health care organizations that use shared governance must have clear communication processes, or the organization will encounter problems and confusion in the decision-making process. Typically, this model leads to greater staff satisfaction with the job and the organization?staff feels empowered (Caramanica, 2004). The key components of shared governance are practice, quality, education, and peer process/governance. How are these accomplished? As with any such change, some organizations change for ?real? and others appear to change to this model, but in the latter situation very little has really changed in the decision-making process or in actual practice. Shared governance is associated with collaboration, horizontal relationships, and investment and need to be demonstrated in the organization. The change has to be real.
Organizations that use this model have some type of structure that relates to the shared accountability, such as councils, cabinets, committees, or a combination of these groups or teams that make the decisions. The chain of command is not the same as in traditional organizations. In the shared governance model these groups make decisions about policies, procedures, and other aspects of getting the work done. How might shared governance be implemented?
Health care organizations have been working for several years to create leaner and more effective organizations. It is important to recognize that to move toward a shared governance model the organization must take a comprehensive change approach and not an incremental approach. All parts of the organization and all staff must be expected to change. This is very difficult to accomplish, but if shared governance is the goal, it is necessary.
Decentralized decision making is now found in many health care organizations, and it is frequently associated with participative management strategies such as a shared government model. This approach to organizational structure and process is associated with the economy, job satisfaction, and retention. For decentralization to be effective staff must have autonomy to make decisions. All of this is intimately connected with shared governance. It requires staff members who are committed to the organization?s values and goals and demonstrate this by working to meet the goals. Magnet hospitals also share these common shared governance characteristics (see Chapter 6). ?Whatever the process of changing structure, locus of control, decision processes, and team-based initiatives are called, they are essential to the future of doing health services business. From shared governance to shared leadership, shared decision making, empowerment, point-of-service accountability, or whatever other name might be attached to the dynamic, shared decision making is an essential element of work of reconceptualizing and configuring health care for the future? (Porter-O?Grady, 2001, p. 473).
Finkelman, A. (2012). Leadership and management for nurses: Core competencies for quality care (2nd ed.). Boston, MA: Pearson.