Theory and Measures for Advancing Nursing Shared Governance

Midwest Nursing Research Society ● Chicago, IL ● March 7-10, 2013

THEORY AND MEASURES FOR ACCELERATING THE PRACTICE OF NURSING SHARED GOVERNANCE:

GEMS

M. Lindell Joseph, PhD, RN Richard J. Bogue, PhD, FACHE

UNIVERSITY OF IOWACOLLEGE OF NURSING

IOWA CITY, IOWA


Objectives

After this presentation, participants will be able to…1. Discuss inputs, processes, and outcomes of nursing

shared governance2. Conceive empirical tests of GEMS a formal theory

of nursing shared governance3. Critique and advance theory, measurement and

practice in nursing shared governance


State of Evidence on Shared Governance

1. What about effectiveness?2. Seen as a pathway to excellence3. Yet ‘cannot be researched directly’

a. Variations in definitions, measures and unitsb. Lack of clarity about processc. Inconsistent findings on outcomes

4. Field needs a stronger theory-practice link5. NPCs are a concrete expression of nursing

shared governance


Study 1. Defining Empowerment for TeamsNPCes: Initial Evidence on Reliability


Study 1. Defining Empowerment for Teams…in a Multi-Level Organizational Context

More Empowered

Nurses(67%)

ORGANIZATIONAL VALUESInformation & Extra-Unit Collaboration(23.90% of variance)

PERSONAL GROWTH VALUES Opportunity & Support(23.82% of variance)

UNIT LEVEL VALUESResources(19.33 % of variance)


Study 2. Defining Empowerment for Leadership

• Group power within organizations Sieloff-King (2003)– Specific to nursing– Adds clarity and richness to measurement of empowerment at

organization & department levels– Group power is the nursing group’s capacity to achieve its

goals. Dimensions of nursing group power include:• Ability to control environmental forces• Power from position• Power from resources• Power from roles• Power perspective• Power competence, and• CNE communication competency


Study 2. Examining Vertical Power & Personality

• Phase I– Online surveys of factors that may enhance or impede

shared governance at three levels• Unit Teams: NPC members• Unit Managers: Nurse Managers & Asst Nurse Managers• Department & Organization: Nursing Directors and CNOs

• Phase II– Delphi study with top organizational executives (n=22)

Attributions Acting Understanding Feeling

Leadership 3% 30% 9%

Workers 36% 9% 12%

Study 2. Executive Empowerment Philosophy

Executive leadership expected workers to act empowered.Executive leadership expected of themselves, not action, but understanding.



Table 1: External Validation and Outcome Measures Associated with the NPC Effectiveness Scale

r† p‡ St±

ORGANIZATIONAL LEVEL MEASURESResources for Goal Attainment (SKAGOAO, Sieloff) 0.562 <0.001 2,3Organizational Support (POS) 0.563 <0.001 3Role (nursing central to the organization’s work, SKAGOAO) 0.430 <0.001 2,3DEPARTMENT LEVEL MEASURESPosition (nursing central in communication network, SKAGOAO) 0.584 <0.001 2,3CNO Communication Competency (SKAGOAO) 0.435 <0.001 2,3Nursing Department Group Power (SKAGOAO) 0.505 <0.001 2,3Control of Environmental Forces (SKAGOAO) 0.599 <0.001 2,3UNIT LEVEL MEASURESStructural Empowerment (CWEQ-II) 0.736 <0.001 1Co-Worker Support (JCQ) 0.431 <0.001 3Manager Support (JCQ) 0.588 <0.001 3Pressure Ulcers (NDNQI) ∆ 0.106 3INDIVIDUAL LEVEL MEASURESJob Satisfaction (RN Survey) 0.234 0.017 1Extroversion (40-item Mini Marker Personality Inventory, Saucier) 0.239 0.002 2Agreeableness (Mini Marker) 0.229 0.003 2Intellectual Openness (Mini Marker) 0.165 0.037 2Conscientiousness (Mini Marker) 0.139 0.079 2Emotional Stability (Mini Marker) 0.114 0.149 2Self Efficacy (IPIP) 0.200 <0.006 3†r = Pearson correlation.‡p = Probability of result, statistical significance±St refers to Study1, Study2 or Study3.∆ NPCes predicted Pressure Ulcer rates at this significance in regression modeling.


Turnkey tools and processes for Nursing Practice Council Effectiveness and Organizational Shared Governance

1. NPCs assess themselves and on nine competencies of effective nursing practice councils

2. Managers and others on the unit also assess NPC3. Leadership and Teams examine unit & roll-up results for

• performance on the nine competencies• team dynamics (within a team & vertically)• vertical alignment in the organization

4. Teams identify one or two competencies to improve5. Teams use provided evidence-based strategies to support NPC

effectiveness, or invent their own strategies6. Repeat assessment every six months

Designing & Testing a Process for Empowerment


Developing a Theory for Shared Governance

• Identify required theoretical attributes for NPC effectiveness, nursing group power, and vertical alignment.

Step 1

• Define each attribute as an observable intervention (Critical Inputs)

Step 2 • Identify the active ingredients for each critical input.

Step 3

• Identify expected outcomes.

Step 4

General Effectiveness Theory for Multilevel Shared Governance(GEM Theory)


Nursing Leadership Team

Nursing Unit Work Team

Use roles & resources expertlyManage external forces

Communicate goalsInfluence decisions

Self-directAlign performance

Empower relationshipsEmpower practices

Build on team foundationsEstablish team foundations

GEMS Effective Shared Governance

Inputs

Inputs

Process

Organization Level

Department Level

Unit Level

Personal Level

Outcomes

Nursing Influence/Power (SKAGO)

Resources for Goals(SKAGO)

Mgr Support (JCQ)Pressure Ulcers

Self Efficacy (IPIP)Job Sat (NDNQI)


Summary and Testable Propositions• GEMS is process theory for engaging nurses at all levels to strive toward

excellence at their level of competencies and aspirations.• Maximizing & aligning nurses’ decision-making authority at all levels

reflects true nursing shared governance. 1. Teams rating higher on NPCes will…

a. More quickly and more widely adopt patient safety protocolsb. Achieve higher rates of quality performance improvementc. Have more satisfied people and less turnover

2. Where leadership rates NPCes higher than care team members do, shared governance will be more marketing than empowering

3. Where both leadership and teams rate low on NPCes, there will be an opportunity for a genuine journey forward together

4. Where both leadership and teams rate high on NPCes, there will be excellence in patient care and nurse engagement


General Effectiveness Multilevel Shared Governance

Formalized GEMS, a practical, measurable, testable multilevel theory

Examined outcomes at individual, unit, department, organizational levels

Needed a measure of leadership competencies for empowerment

Needed a process for multilevel empowerment

Needed a practical, competency-based measure of team effectiveness


References• Anderson, E., Faye. (2011). A case for measuring governance. Nursing Administration

Quarterly, 35(3), 197-203. • Anthony, M. K. (2004). Shared governance models: The theory, practice, and evidence.

Online Journal of Issues in Nursing, 9(1). 3.• Argyris, C. (2004). Reasons and rationalizations: The limits to organizational knowledge.

Oxford: University Press.• Bogue RJ, Joseph ML & Sieloff CL. (2009). Vertical Alignment of Nursing Group Power

and Nurse Practice Council Effectiveness. Journal of Nursing Management, 17:4-14.• Hess, R., J. (2004). From bedside to boardroom -- nursing shared governance. Online

Journal of Issues in Nursing, 9(1), 10p. • Joseph, R., Bogue, R., & Thompson, J. (2006). Nursing practice councils: A Formative

Assessment. Research Report. Florida Hospital.• Kanter, R. (1977). Men and Women of the Corporation. New York: Basic Books.• Porter-O'Grady, T. (2004). Shared governance: Is it a model for nurses to gain control

over their practice? Online Journal of Issues in Nursing, 9(1), 1. • Sieloff, C. L. (1995). Development of a theory of departmental power in advancing King’s

systems framework and theory of goal attainment. Sage Publications.• Saucier, G. (1994). Mini-Markers: A brief version of Goldberg's unipolar Big-Five

markers. Journal of Personality Assessment, 63, 506-516.• Sieloff, C. L. (2004). Leadership behaviors that foster nursing group power. Journal of

Nursing Management. 12, 246-251.• Wright, T. A. (2003). What Every Manager Should Know: Does Personality Help Drive

Employee Motivation? The Academy of Management Executive. 17(2). 131.

M. Lindell Joseph, PhD, RNEmail: [email protected]

Richard J. Bogue, PhD, FACHEEmail: [email protected]

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Theory and Measures for Advancing Nursing Shared Governance