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Exploring how nurses and managers perceive shared governance By Janet Wilson, BSN, RN; Karen Gabel Speroni, PhD, RN; Ruth Ann Jones, EdD, MSN, RN, NEA-BC; and Marlon G. Daniel, MPH, MHS

Abstract Background: Nurse managers have a pivotal role in the success of unit-based councils, which include direct care nurses. These councils establish shared governance to provide innovative, quality-based, and cost-effective nursing care. Purpose: This study explored differences between direct care nurses’ and nurse managers’ perceptions of factors affecting direct care nurses’ participation in unit-based and general shared governance activities and nurse engagement. Methods: In a survey research study, 425 direct care RNs and nurse managers were asked to complete a 26-item research survey addressing 16 shared governance factors; 144 participated (response rate = 33.8%). Results: Most nurse participants provided direct care (N = 129, 89.6%; nurse managers = 15, 10.4%), were older than 35 (75.6%), had more than 5 years of experience (76.4%), and worked more than 35 hours per week (72.9%). Direct care nurses’ and managers’ perceptions showed a few significant differences. Factors ranked as very important by direct care nurses and managers included direct care nurses perceiving support from unit manager to participate in shared governance activities (84.0%); unit nurses working as a team (79.0%); direct care nurses participating in shared governance activities won’t disrupt patient care (76.9%); and direct care nurses will be paid for participating beyond scheduled shifts (71.3%). Overall, 79.2% had some level of engagement in shared governance activities. Managers reported more engagement than direct care nurses. Conclusions: Nurse managers and unit-based councils should evaluate nurses’ perceptions of manager support, teamwork, lack of disruption to patient care, and payment for participation in shared governance-related activities. These research findings can be used to evaluate hospital practices for direct care nurse participation in unit-based shared governance activities.

Background 1. Responsibilities for nursing care Hospitals are continuously seeking delivery must reside with clinical opportunities to improve their per- staff. formance by providing innovative, 2. Authority for nurses to act must quality-based, cost-effective care. be recognized by the organization. Principles of shared governance have 3. Accountability for quality patient been integrated in nursing infrastruc- care and professionalism must be tures as a means of providing a trans- accepted by the clinical staff.1

formational framework for direct care Shared governance activities give nursing staff and improving an orga- direct care nurses an opportunity to nization’s overall performance. The partner with nursing management to three core principles associated with achieve optimal patient outcomes shared governance are as follows: and to increase nurse job satisfaction,

nurse productivity, and nurse reten-tion.2 Shared governance provides the framework for a collaborative environment of nursing leaders and direct care nurses. Together, they can formulate a partnership of shared decision making for clinical and operational practices.3

Direct care nurses play a vital role in helping realize the objectives set forth in the 2010 Affordable Care Act.4 Nurses need to overcome barri-ers that prevent them from respond-ing effectively to rapidly changing healthcare settings.

Direct care nurses’ and nurse man-agers’ perceptions of direct care nurse participation in shared gover-nance need to be explored. When direct care nurses and nurse manag-ers recognize differences in their per-ceptions, ideally they can improve unit-based and overall shared gover-nance by leveraging the diversity that these two different perspectives can provide to improve patient outcomes.

The literature lacks an examina-tion of direct care nurse or nurse manager factors perceived as impor-tant for direct care nurse participa-tion in unit-based and overall shared governance activities. Also absent is a delineation of identifiable differences by nurse job responsibilities and fac-tors important to both direct care nurses and nurse managers for direct care nurse participation in shared governance.

For the literature review, PubMed, EBSCOhost, ProQuest, and the

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Cochrane Library databases were searched for the years 2006 to 2012. Search terms included engagement, physician-nurse relationship, relationship-based care, shared governance, staff nurse participation, participation, bar-riers, and positive nursing workforce environments.

This survey study was conducted to identify factors that could be used by nurse managers and shared gov-ernance leaders (unit council chairs) to strengthen direct care nurse par-ticipation in shared governance activities at the unit level. The researchers created the study survey based on factors about shared gover-nance derived from the literature review and hospital direct care nurses’ perceptions.

The study was conducted at Shore Health System, a two-hospital, not-

for-profit, rural healthcare system located in Easton and Cambridge, Md. The healthcare system, which obtained American Nurses Creden-tialing Center (ANCC) Magnet®

recognition in October 2009 and redesignation in 2014, has 188 licensed beds and employs about 500 nurses. Members from the hos-pitals’ nursing research council served as the 11-member panel that performed content validity for rel-evance and clarity of a 26-item sur-vey. (See Glossary of research terms.) Members rated each survey question according to a 4-option relevance scale (1 = not relevant, 2 = somewhat relevant but unable to assess ques-tion relevance without major revi-sions, 3 = quite relevant but needs minor revisions, and 4 = relevant). The panel also rated the clarity of

Glossary of research terms • Bonferonni corrections. A statistical adjustment used in the case of multiple

simultaneous comparisons to reduce the chance of committing a type I error (the probability of rejecting the null hypothesis when it’s true).

• Chi-square analysis. A statistical method used to test the association between two nominal variables based upon the Chi-square distribution.

• Content validity. Measures how well a particular scale or indicator variable explains or represents a theoretical construct.

• Convenience sampling. A nonprobability-based method of sampling that selects individuals based on accessibility.

• Fisher exact tests. Similar to a Chi-square test in that it’s testing the associa-tion between two nominal variables, where the nominal variables have only two categories.

• Frequency distribution. The classification of all values in a particular variable that are collected in a study.

• Likert scale. A symmetric rating scale that allows respondents to indicate their agreement with a stated question or construct.

• P value. The probability that a sample’s effect or estimate is as large or larger in the population given that the null hypothesis is true.

• Scale content validity index. The degree to which a scale’s content validity assesses the underlying construct(s) being measured.

• Selection bias. A systematic bias in the statistical results of a study that’s attributed to the selection of study participants.

each question on the survey accord-ing to a 4-option clarity scale (1 = not clearly written with no potential for revision, 2 = not clearly written and needs major revision, 3 = clearly written, but needs minor revision, and 4 = clearly written). The panel received content validity forms for the survey, a copy of the survey, the study abstract, and instructions for evaluating the survey. Based on panel responses, questions with 80% or greater agreement about question relevance and clarity were retained, and those with less than 80% agreement were revised. The final panel review generated a scale content validity index of .94 for the 26-item survey (demo-graphics = 8 items; shared gover-nance activities = 1; engagement level = 1; and shared governance perception factors = 16).

Purpose The study’s purpose was to explore differences between direct care nurses’ and nurse managers’ percep-tions of specific factors that could affect the direct care nurses’ partici-pation in unit-based and general shared governance activities. Factors associated with direct care nurse engagement were also explored.

Methods In this survey research study, data were collected from September to November 2011. Inclusion criteria for the study included direct care nurses and nurse managers who were employed in the categories of full-time, part-time, relief, or week-ends. Nurses who were employed on a per diem or temporary basis were excluded.

The principal researcher delivered study packets to eligible nurses’ unit-based mailboxes. The study packet consisted of a one-page letter

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describing the study, the institu-tional review board-approved informed consent form, the survey instrument, and an interoffice enve-lope preaddressed to the researcher. Of the 425 eligible direct care nurses and nurse managers asked to participate, 144 returned surveys (response rate = 33.8%).

The 26-item survey asked nurses to self-report perceptions of activities in which they’d participated over the past year and their level of engagement. For purposes of this research, engaged was defined as a nurse who’s fully involved and enthusiastic about his or her work and who acts in a way that furthers nursing on the unit.

The survey also asked nurses 16 questions associated with their per-ception of the importance of several specified factors that affect direct care nurse participation in shared gover-nance activities. These were mea-sured with a 5-point Likert scale (1 = not at all important; 2 = not very important; 3 = neutral; 4 = somewhat important; and 5 = very important).

The study was continued until a minimum target sample of surveys had been received (N = 128), or 30% of the system’s eligible 403 direct care RNs (N = 121) and 22 nurse managers (N = 7). The study was designed to let the target sample size be met; additional surveys were received during this time.

Statistical analyses were completed using SAS (version 9.1.3, Cary, NC). Frequencies distributions were calcu-lated to describe the survey items. In addition, Fisher exact tests and Chi-square analysis examined the differ-ences and associations between the study groups for each study item/ response. Bonferonni corrections were used in cases of multiple com-parisons to reduce error.

Results Of the 144 nurses participating in this study, 129 (89.6%) were direct care nurses and 15 (10.4%) were managers. Most participants were over age 35 (75.6%), had an associ-ate’s degree (37.5%), had more than 5 years of experience (76.4%), and worked more than 35 hours per week (72.9%).

Direct care nurses and managers differed significantly in their educa-tion, years of experience, and hours worked per week. Managers were typically older and had more edu-cation and more experience. The largest percentages of nurses who participated in the survey worked in the ED (15.3%) and medical/surgical/ oncology unit (12.5%). No signifi-cant differences in the survey results were seen between the two system hospitals.

Two significant differences in direct care nurses’ and managers’ perceptions for the shared gover-nance factors evaluated were noted: “direct care nurses perceiving nurses on the unit work as a team” in the response category of “very impor-tant” (direct care nurses = 76.6%, managers = 100%, P = 0.05); and “direct care nurses feeling they have the ability to make changes at unit level,” also for the response category of “very important” (direct care nurses = 62.0%, managers = 93.3%, P = 0.05).

The top four factors ranked as “very important” overall (direct care nurse and nurse manager responses combined) were: 1. direct care nurses perceiving sup-port by unit manager (very impor-tant overall = 84.0%, direct care nurses = 83.0%, managers = 93.3%) 2. direct care nurses perceiving nurses on unit work as team (very important overall = 79.0%, direct care nurses = 76.6%, managers = 100%, P = 0.05)

3. direct care nurses feeling time to participate in activities without disrupting patient care (very impor-tant overall = 76.9%, direct care nurse = 75.8%, managers = 86.7%) 4. direct care nurses believing they’ll be paid for activities beyond scheduled shift (very important overall = 71.3%, direct care nurses = 72.7%, manager = 60.0%).

Regarding activity participation during the previous year, managers reported a higher participation rate for 11 of the 12 activities measured; of these, all but three were statisti-cally significant. Direct care nurses reported more activity for only one category, which was “charge nurse when designated” (direct care nurse = 68%; manager = 33.3%). Regard-ing engagement level, 79.2% of participants had some level of engagement. A significantly higher percentage of managers were very engaged compared with direct care nurses (direct care nurses = 36.4%; managers = 86.7%).

Discussion As a result of this research, four primary factors were identified that were perceived by direct care nurses and nurse managers to influence direct care nurse partici-pation in shared governance activi-ties. (See What factors influence shared governance participation?) Ideally, to strengthen direct care nurse participation in shared governance activities both at the unit level and in general, nurse managers need to focus on the following: • supporting direct care nurses’ participation in shared governance activities • ensuring unit nurses work as an effective team • ensuring that no disruptions to patient care occur as a result of

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What factors influence shared governance participation?

nurses participating in shared governance activities • ensuring that nurses are paid for participation in shared governance activities.

Our findings support shared governance survey research that assessed the knowledge, commit-ment, and perception of shared gov-ernance.5 These earlier research results showed a need to enhance enabling factors and to reduce the barriers associated with shared gov-ernance. Shared governance enabling factors were continued management support, providing council members time to do their work, and providing education to council participants on the roles and processes of shared governance. This additional focus on shared governance activities will enhance the opportunity for direct care nurses and managers to evaluate their partnerships aimed at achiev-ing optimal patient outcomes and increasing nurse job satisfaction, nursing productivity, and nursing retention.2

Additional research is needed to define clear shared governance out-

COMPENSATION

Direct care nurses are

paid for participation

in shared governance

activities

OPTIMAL PATIENT

CARE

Participation in

shared governance

doesn't disrupt

patient care

Direct care nurse

participation in

unit-based and

overall shared

governance

activities

TEAMWORK

Unit nurses work as

an effective team

SUPPORT

Nurse managers

provide support for

direct care nurses to

participate in shared

governance activities

comes and attributes such as par-ticipation, scope of decisions, and level of authority to lead to the implementation of strategies that may predict the long-term success of shared governance within organi-zations.5 The traditional approach to engaging direct care staff nurses in daily activities also needs to be studied if managers are conducting more quality improvement activi-ties, evidence-based practice proj-ects, and research studies than direct care nurses. Research is also needed to identify relationships between shared governance (the degree to which it’s present in an organization) and the organization’s outcomes, such as those nursing sensitive indicators reported in national databases.

A limitation of this study is the selection bias inherent with survey research designs employing conve-nience sampling. Nurses participat-ing in this survey may have been more engaged than nurses who chose not to participate. Also, these findings may not be generalizable to hospitals in nonrural settings or to those without ANCC Magnet

recognition. Also, a limited number of nurse managers were included in this study. Research in larger hospi-tal systems having more nurses and managers is suggested.

Conclusions Based on these study findings, nurse managers and unit council leaders/members should evaluate their nurses’ perceptions of man-ager support, teamwork, lack of disruption to patient care, and pay for their participation in shared governance-related activities. These research findings can be used to facilitate evaluation of hospital practices for direct care nurse par-ticipation in unit-based shared gov-ernance activities. ■

REFERENCES

1. Anderson EF. A case for measuring governance. Nurs Adm Q. 2011;35(3):197-203.

2. Frith K, Montgomery M. Perceptions, knowl-edge, and commitment of clinical staff to shared governance. Nurs Adm Q. 2006;30(3):273-284.

3. Gavin M, Ash D, Wakefeld S, Wroe C. Shared governance: time to consider the cons as well as the pros. J Nurs Manag. 1999;7(4):193-200.

4. Howell JN, Frederick J, Olinger B, et al. Can nurses govern in a government agency? J Nurs Adm. 2001;31(4):187-195.

5. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2010.

At Shore Health System in Easton, Md., Janet Wilson is the chair of nursing shared leadership and faculty for Critical Care and Graduate University (a hospital-based nurse residency program); Karen Gabel Speroni is chair of the nursing research council; Ruth Ann Jones is director of acute care; and Marlon G. Daniel is a statistician and faculty for Critical Care and Graduate University.

Research Corner is coordinated by Cheryl Dumont, PhD, RN, CRNI, director of nursing research and the vascular access team at Winchester Medical Center in Winchester, Va. Dr. Dumont is also a member of the Nursing2014 editorial board.

The content in this article has received appropriate institutional review board and/or administrative approval for publication.

The authors have disclosed that they have no fnancial relationships related to this article.

DOI-10.1097/01.NURSE.0000450791.18473.52

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