Interdisciplinary Collaboration in Shared Governance: Supports, Challenges, and Barriers
Over time, there has been a growing need to reorganize healthcare institutions. The reason behind the reorganization has been to strategically position healthcare institutions in the marketplace. One of the ways has been to improve on how a nurse can best respond to a situation. Overall, the move to reorganize health care institutions has been motivated by a need to deliver better healthcare. In order to provide an effective context and structure for reorganizational strategies, nursing practice models have been employed. One of the models which has been popularly used to improve delivery of care is the shared governance (SG) model. In SG model, the beliefs which are embraced by the professional nursing practice are integrated with their core values with the overall goal of achieving quality health care. Shared governance has been also employed as a tool for improving nurses job satisfaction, retention, and working environment (Anthony, 2004).
For many years, SG has played an essential role in the management of employees. In addition to that, it was viewed as a strategy that would ensure that nurses had control over decisions that had a direct effect on their practice (Upenieks, 2003). Adminstrators of healthcare institutions faced a major challenge. They had to ensure that their facilities maintain excellent professional but at the same time striving to achieve practice in a resource and cost constraint environment while at the same time focusing on positive nurse, organizational, and patient outcomes. The primary reason for the introduction of SG model in the nursing profession was the shortage of nurses. Nursing shortage has been found to be a universal (Thomas, Reddy, & Oliel, 2016). Like the rest of the world, the Middle East also suffers from nursing shortage arising from low number of students interested in pursuing a nursing career and the increasing demand of nurses. Studies suggest that students avoid enrolling in nursing programs because they believe that nursing profession is not only stressful but also highly demanding. Besides occupational stress, there is a perception that nursing job dissatisfaction. Following this shortage, there has been proposal to reverse the perceptions and make nursing profession attractive and highly rewarding. Among the proposed measures are improving work conditions by eliminating job stressors, better remuneration, recognition of nurses, and awards for best performance (Elmobasher, 2007). There has been also suggestions to change the image of nursing profession by influencing school going children at a younger age. As mentioned previously, there are many reasons leading to nurses shortage, including lack of autonomy in their practice, low wages, poor prestige, and poor working conditions. Furthermore, these factors resulted in decreased job satisfaction that adversely affected recruitment and retention rates. SG has received much credit for being the solution to the problem of nurses shortages, retention rates, advancing the profession, and expanding the autonomy of practice and improving the work life of nurses (Twigg and McCullough, 2014 ). The increasingly shortage of professional nurses is a pertinent issue that may have negative effects in the delivery of healthcare. As a result, several health care organizations began focusing on shared governance (Ballerd, 2010; Newman, 2011; Twigg and McCullough, 2014). The concept of shared governance is not new. Although it has been education, politics, philosophy, management, religion, and business, it was not until 1970s and 1980s when it found its way in the nursing and healthcare arenas in the USA. In the corporate world, businesses has been striving for organizational performance. Management and leadership has been found to be aspects which can be used to drive organizational performance. Shared governance has been employed in business to improve leadership and management in organizations and also to improve decision-making among the various stakeholders. The nursing profession began applying the concept of SG in the late 1970s and early 1980s, and the first hospitals that implemented SG were in the United States (Ballerd, 2010; Newman, 2001). The introduction of SG has led to many benefits including shared decision-making, accountability, collaboration, and improved safety, quality of care, and enhanced working life.
In the past decade, the SG model was introduced in three hospitals in the Middle East: the American University of Beirut Medical Center in Beirut, Lebanon in 2005); King Hussein Cancer Center in Amman, Jordan in 2009; and King Faisal Specialist Hospital and Research Centre in Jeddah, Saudi Arabia in 2013. It has been observed that there is a need to improve the management process of the facilities with the goal of improving workplace conditions for nurses, motivate them, and also to improve the quality of care. The first thing to do is to assess the facilities to find out negative workplace behaviors that contribute to dissatisfaction and poor quality care. A number of theories have been found useful for studying workplace structure. Kanters theory on structural power has played a fundamental role in the formation and development of SG models (Anthony, 2004). Kanters assumptions suggest that formal and informal powers enable nurses to access work empowerment structures, which include information, support, opportunities and resources. In addition to that, Kanters theory has been viewed as a strategy that would ensure that nurses has control over decisions that had a direct bearing in their practice (Upenieks, 2003). Being empowered suggests a model of shared governance where decisions are made at the point of service delivery (Anthony, 2004). According to Kanter, organizations need to reorganize the structure of workplace environment to change the way employees perceive access to power. Kanter pointed out that some of the ways employees need to be empowered include access to power, opportunity, resources, and information. Kanter further suggested that employees ought to be given access to empowerment structures associated with the degree of informal and formal power they have in the organization (Nedd, 2006).
The design of a nursing SG model is essential for its success. Several types of councils or committees that support a nursing SG model depending on the needs of the individual hospital. Typical councils, as shown in Figure 1, include Operations Council, Practice Council, Quality Improvement Council, Education Council, Management Council, and Coordinating Council. The Operations Council is where all the ideas, issues, and information come together so that it can be dispersed to all the people affected, and issues can be addressed.
The issues addressed by the various councils will be issues that directly depend on their expertise and specialty. For instance, the need for continuing education and training is addressed by the Education Council. The coordinating of activities between councils is done by the Coordinating Committee. While the committees are able to function independently, they also have the option of collaborating with the other committees with all information and decisions they make to the Operations Council (Dunbar, 2007; Force, 2004). Unit councils are able to make decisions at their unit level, and they are part of the larger SG council. In some circumstances, the unit councils may take their concerns or questions to a specific committee and are also given the opportunity to serve on designated committees. Even though nurses make their contributions during decision making at the unit level, the final approval is done by management or staff at a high level who are responsible for coordination of the work and ensuring there is no duplication.
Shared Governance Outcomes
Research has shown that SG has a positive outcome in patients, nurses and organizations. Decrease in mortality rates, decrease in pressure sores and falls and increase in patients satisfaction are some of the patient outcomes (American Nurses Credentialing Centre, 2015; Armstrong & Laschinger, 2006). Benefits to nurses include: increased job satisfaction, improved mental health, increased autonomy and reduced burnout (Aikens & Havens, 2000; Hess 2004; Kramer & Schmalenberg, 2003; Tiger, 2004). As well, SG increases the sense of empowerment in nurses (Kramer et al., 2008) by giving nurses a bigger voice in decision-making processes. SG also enables an organization to benefit in different ways, including: attraction and retention of qualified staff, improvement in the quality of patient care, improvement in communication and teamwork, and nurturing a collaborative culture (American Nurses Credentialing Centre, 2015; Mouro, Tashjian, Bachir, Al-Ruzzeih, &Hess 2013).
SG is considered a journey involving a commitment to integrate interdisciplinary units to collaborate in the promotion of quality care (Hess, 2004). Most of the interdisciplinary SG models are relatively new and their primary purpose is to improve inter-professional collaborations and initiatives (Brewton, Eppling, & Hobley, 2012; Hoying & Allen, 2010).
Anthony, M.K. (2004). Shared Governance Models: The Theory, Practice, and Evidence. Online Journal of Issues in Nursing, 9(1). Retrieved from: http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume92004/No1Jan04/SharedGovernanceModels.aspx
Elmobasher, M. (2007). Nursing Shortage, Causes and Possible Solutions. Middle East Journal of Nursing, 1(4). Retrieved from: http://www.me-jn.com/archives/NursingShortage.htm
Nedd, N. (2006). Perceptions of Empowerment and Intent to Stay. Journal of Nursing Economics, 24(1), 13-18.
World Health Organization (WHO). (2016). Global health workforce shortage to reach 12.9 million in coming decades. Retrieved from: http://www.who.int/mediacentre/news/releases/2013/health-workforce-shortage/en/