Promoting the Nursing Profession Through Shared Governance
Submitted by Nancy Bellucci, PhD, MSN-Ed, MS, RN, CNE, CNOR
This article takes a historical look at the image of nursing from the days of Nightingale. The nursing profession is strained and incivility is on the rise. Now is the time to go back to the basics and look through the lens of shared governance to promote the profession and preserve its numbers.
"Nursing is an art: and if it is to be made an art, it requires an exclusive devotion as hard a preparation, as any painter's or sculptor's work; for what is the having to do with dead canvas or dead marble, compared with having to do with the living body, the temple of God's spirit? It is one of the Fine Arts: I had almost said, the finest of Fine Arts" (Nightingale, 1946, n.p.). The image of nursing has changed since the days of its founder; however, devotion is the same. Nursing as a profession, coupled with the men and women who make up its numbers, functions as the first line of defense for their patients. Therefore, stewardship, governance, and advocacy for the profession must be employed by nursing leaders for its protection and progression. In a time when the nursing profession is strained, incivility is on the rise, and turnover is greater than ever, we need to get back to the basics. This includes appreciating where the profession began and working to promote and protect its future.
The Historical Image of Nursing
Sometimes known as handmaidens to doctors, in the 1800's nurses filled the role of the oppressed yet diligent assistant to the perceived-as-knowledgeable physician. This subservient behavior was met with a change in the mid-1800s, upon the arrival of Florence Nightingale. Nightingale is known as a nursing pioneer and the founder of nursing as a profession (Summers & Summers, 2004). Further, she is responsible for making nursing recognized as a trained profession requiring formal training and education (Summers & Summers, 2004). She was the first advocate for nursing in recorded history. Not only did she function as a nurse who cared for the sick and debilitated during the Crimean War, but she is also the first recorded nurse researcher. She established statistical methodology and analysis to record disease and mortality (Alexander, 2019). She held the position of General Superintendent of the Female Nursing Establishment of the Military Hospitals of the Army. She was the founder of the Nightingale School and Home for Nurses in London (Alexander, 2019). By 1901, although completely blind, Florence Nightingale became the first woman in history to receive the Order of Merit from the King (Alexander, 2019). During her career, her voice as a nurse never fell silent. In current-day nursing schools, her efforts and intelligence are not forgotten and are used to create a foundation for future practice.
The Image of Leadership in Nursing
The nursing profession is a vital component of a functioning society. Nurses fill the roles of educator, facilitator of care, administrator, counselor, and advocate. Nursing leaders have a pivotal role in the process of progress and change for the profession. They are the representatives and the face of their departments. Murphy contended (2009) that nursing leaders must exercise stewardship at the point of service and work to advocate for respectful interactions with patients and the promotion of a just culture. Murphy (2009) defined stewardship as a concept that includes the philosophy of practical analysis. It is a practice of serving others in such a way as to provide leadership while observing the shared values of the staff for which they are in charge. The staff is the intrinsic force in a department; therefore, its steward's goal is to serve, protect, and perpetuate its growth and function (Murphy, 2009).
The steward at the point of service must be aware of challenges and differences while acting to cultivate these aspects into objective and impartial practices. The impact a manager or steward can make upon a given group is monumental if fundamental assessments are made of the staff as a whole and the individuals who comprise its numbers. Likewise, a staff member can promote their practice while creating change through the effective communication of ideas and observations made on patient care. Further, the transformation of current practice into a more efficient delivery of care can be facilitated by open collaboration with nursing leaders and physicians. They direct the interventions implemented by the nurse. A realization that we are all in this together would serve to impact nursing in such a positive way. Therefore, the nurse leader must be active in their role as an advocate not only for the care of the patient but for the good of the staff providing care.
Improving Nursing Through Shared Governance
Shared governance is a term that was introduced over twenty years ago and was used to provide actionable strategies to provide nurses with power over their practice. Green and Jordan identified that shared governance is a collaborative strategy used by organizations to encourage nursing staff to manage their practice at a high level (Green & Jordan, 2004). Shared governance acts as a partnership between the institution, the nurse leader, and the nurse that encourages a higher level of commitment to practice (Green & Jordan,2004). Further, the process of shared governance works to stimulate workplace advocacy, which operates at the local, state, and national levels of government. Simply put, shared governance provides nursing with a vehicle to promote their collective voice. A means of practice standards have been provided by many sources, most notably the American Nurses Association (ANA). The practice standards provided by the ANA (2020) support and promote professional practice and serve as a guide in the education of nurses entering the field for the first time.
As cited by Green and Jordan (2004), four key concepts function to create shared governance and workplace advocacy, which are accountability, empowerment, conflict resolution, and patient advocacy. Green and Jordan (2004) also contended that accountability functions as the foundation for strategies created to promote shared governance and workplace advocacy. An individual must realize current workplace issues and be armed with the knowledge to address the issues at the onset. Green and Jordan contend that the ability to recognize and resolve problems contributes to the level of success and accountability of a nursing professional (Green & Jordan, 2004).
Empowerment is the primary function of shared governance and workplace advocacy (Green & Jordan, 2004). The primary objective of each works to strengthen the voice of the nursing profession and ensures its active involvement in decision-making and process change. Nurse staffing, an issue that is recognized as a problem nationwide, is just one aspect of policy change that is directly impacted by the participation of nursing in a hospital's nurse management council. Without nurse leaders, staff participation, and the use of collective knowledge of patient care implications related to poor staffing ratios, policies will not change. Therefore, the patient and the staff associated with the care suffer greatly.
Conflict resolution is another concept associated with shared governance and workplace advocacy. It is important because it affects every relationship within an organization. Not only patient-to-nurse, but it can debilitate an institution if overlooked. The improvement of patient care delivery and the overall work environment requires a non-hierarchical decision-making process and work design (Green & Jordan, 2004). Conflict resolution can serve to promote a unified nursing workforce, provide cost-effective work behaviors, and empower the body of an organization. Green and Jordan (2004) asserted that nurses do not have the skills required to resolve conflicts promptly; therefore, leaders are required to provide education on the issues as the need arises.
The Influence of Healthcare Leadership - Creation of Legislation
Abood (2007) contended that nurses and nursing leaders are already aware that health care reform is needed and that they are the first to see a breakdown in the efficiency and efficacy of patient care. Therefore, it is the nursing profession's collective responsibility to promote change (Abood, 2007). Further, to be an effective advocate for change, one must possess the desire, will, time, and energy required to engage in reform at the legislative level (Abood, 2007). There are a growing number of uninsured patients, a rise in the costs associated with providing quality care, and a continual decrease in the healthcare workforce. These problems impose a great strain on the nurses currently in practice. The strain further imposes the numbers of those who choose to be involved in reform. The current workforce is under excessive stress, which directly corresponds to a lack of interest in representing themselves or sharing their collective voice. Work stress aside, Abood asserts that nurses find it difficult to leave the comfort of their practice to engage in the battle to be heard by their legislators (Abood, 2007).
However, without representation from the nursing leadership in practice, policies cannot be changed. It is the combined knowledge and field experience held by the nursing profession that is needed to influence those who make policies for change to occur. Abood (2007) expressed that leaders can exercise five types of power with great force if the nursing profession would band together to employ their use (Abood, 2007). The forces of power are expert power, legitimate power, referent power, reward power, and coercive power. Expert power refers to the unique training and education that is required by nursing (Abood, 2007). Legitimate power refers to the requirement of licensing to practice that is observed by the profession (Abood, 2007). Referent power is bestowed upon nursing in the form of admiration and respect from the patients that nurses offer the provision of care (Abood, 2007). Reward power is the ability to provide what others desire and to perceive the act as desirable in return (Abood, 2007). Reward power is committed every time the nurse provides intervention for a patient or when a leader bestows praise on a member of the nursing staff. Lastly, coercive power is seen as a more negative power element and is usually exercised by the government in the form of taxation, policy, or punishment for the crime (Abood, 2007). However, coercive power can be a motivator. For instance, unions exercise coercive power when demands are not met, and the result is an employment strike; or, leaders can exercise coercive power by leveraging staffing requests.
Future Challenges for Nursing Leadership
Nursing leadership will encounter greater challenges in the near future. Lee, Daugherty, and Hamelin (2017) contend that human capital management, digital technology advancement, and cost control are three of the major challenges and opportunities that nursing leaders will face in the 21st Century. Further, Lee et al. (2017) maintain that nursing leaders will play a critical role in transforming healthcare through active participation in the nursing units and executive boardrooms. Critical issues, such as an aging population and the nursing shortage, continue to be prevalent in the United States and globally. Therefore, nursing leaders will need to address issues that affect retention and create new ways to promote the profession. Other issues, such as the expansion of digital technology use and development, will require the nursing leaders to ensure that appropriate education is provided to staff and that associated competencies for use are achieved. Lastly, the nursing leader will need to ensure that quality, safety, collaboration, and efficient care are provided in order to promote positive patient outcomes and experiences. By working to maintain all aspects of care at a high level, reimbursement needs are achieved, and the growth of the organization is possible.
Nursing leaders need to expand upon the foundation created by nursing pioneers such as Florence Nightingale. The integration of shared governance into the workplace begins with the nursing leader. There also needs to be a collective effort to revise and reform policies at all levels of administration within an institution and our state and national governing bodies. There is a legacy to uphold. By joining state nursing associations and showing solidarity, the profession has the potential to serve the public in a much larger capacity. The nurse leader has many challenges ahead. In taking pride at the bedside, the nurse has the power to impact not just those that he or she serves, but the families, administrators, and peers alike. Our presence can be our voice, as well. The mere act of diligence in duty and respect for oneself translates more than words can convey.
- Abood, S. (2007). Influencing health care in the legislative arena. The online journal of issues in nursing, 12(1). http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No1Jan07/tpc32_216091.aspx
- Alexander, K. L. (2019). Florence Nightingale. from https://www.womenshistory.org/education-resources/biographies/florence-nightingale
- American Nurses Association (ANA). (2020). About ANA. from https://www.nursingworld.org/ana/about-ana/
- Green, A. & Jordan, C. (2004). Common denominators: Shared governance and work place advocacy – strategies for nurses to gain control over their practice. The online journal of issues in nursing, 9(1). http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume92004/No1Jan04/SharedGovernanceandWorkPlaceAdvocacy.html
- Lee, E., Daugherty, J., & Hamelin, T. (2019). Reimagine health care leadership, challenges and opportunities in the 21st Century. Journal of PeriAnesthesia Nursing, 34(1), 27–38. https://doi-10.1016/j.jopan.2017.11.007
- Murphy N. S. (2009). Nurse leaders as stewards: the beginning of change. The open nursing journal, 3, 39–44. https://doi.org/10.2174/1874434600903010039.
- Nightingale, F. (1946). Notes on nursing: What it is, and what it is not. Philadelphia: J.B. Lippincott.
- Summers, S. J. & Summers, H. J. (2004). Media 'nursing': Retiring the handmaiden. https://www.nursingcenter.com/pdfjournal?AID=483200&an=00000446-200402000-00002&Journal_ID=54030&Issue_ID=483197