Nurses operating within a healthy work environment typically function within the framework of a PPM (Tinkham, 2013). Practice models graphically represent a conceptual framework which describes the organization’s structures, processes, and outcomes supporting nurses’ control over their practice and environment (Basol, Hilleren-Listerud, & Chmielewski, 2015; Stallings-Welden & Shirey, 2015). PPMs generally include five key components: professional values, relationships, patient care delivery, recognition, and shared governance (Hoffart & Woods, 1996).
Background
The Nursing Department developed a strategic plan focused on achieving nursing excellence using the American Nurses Credentialing Center’s (ANCC) (2018) Magnet® Recognition Program standards as its benchmark. In developing a high-leverage strategy, nurse leaders focused resources to establish a Nursing Professional Practice Model (NPPM) with a strong shared governance structure. The resulting NPPM encompasses three domains of practice: Knowledge Structure, Care Delivery System, and Professional Environment with each domain comprising three components, all of which are integral to each other and involve multiple mutual processes. The Knowledge Structure Domain emphasizes the valuing of nurses for their knowledge contributions and includes three components: 1) foundational statements of mission, vision, and values; 2) an eclectic theoretical framework formulated around the Therapeutic Capacity practice theory (Waters and Daubenmire, 1997); and 3) a well defined clinical inquiry system. The Care Delivery System Domain describes the system of care that delineates the nurse’s authority and accountability for clinical decision making and outcomes. This domain has three components: Nursing Practice delivery structure, a Information Systems, and Quality Management.
The NPPM’s Professional Environment Domain is designed to empower and enhance the professional nurse and his/her work environment and includes three components: Professional Development, a Differentiated Practice program congruent with Benner’s model for advancing clinical expertise, and a uniquely designed Shared Governance structure. The shared governance component is critical to the effective implementation of the NPPM. Practicing within an empowering shared governance framework, clinical nurses possess the ability to engage in collaborative care, voice their priorities, and make decisions related to practice (Hill & Prevost, 2011). The shared governance component has been and continues to be pivotal in creating a healthy PPE at the unit, service, and institutional levels.
Shared Governance: A Community of Practice Model
The shared governance system within this healthcare organization embodies the principles of accountability, equity, and partnership that Woten and Heering (2018) state provides the framework for a healthy work environment. In a healthy work environment, nurses feel empowered to control and regulate their professional practice through shared decision making between administrative leaders and clinicians. Shared governance also provides the foundation for engagement in meaningful communication and collaboration, allowing the NPPM to become an effective mechanism for directing and evaluating nursing practice and strengthening the professional environment.
The strategic planning group recognized a need for a structure that facilitated nurses engaging in teams, as well as organizational level decision making regarding practice and professional issues. To achieve this objective, the planning group investigated the concept and implementation of Communities of Practice (CoPs). According to Wenger and Wenger-Traynor (2015) who introduced the idea, a CoP emerges from within a group of people who share a common purpose and engage in collective learning, fueled by passion to enhance their capacity to perform better through regular interaction and mutual support (Smith, 2003). According to the literature, CoPs are commonly seen in business and education settings but the characteristic components (domain, shared practice, and community) are applicable to health care and professional nursing.
Domain describes an interest in which members identify (i.e., the profession of nursing), sustain a shared competence and commitment to the domain, and are distinguishable from other people. The element of shared practice is characterized by members who are practitioners in their specialty field and interact with each other through a common toolkit or resources of tools and experiences (i.e., obstetrical nursing and how to manage emergency delivery). Lastly, the characteristic of community is exhibited through social and professional relationships and members’ participation in activities and discussions that enable sharing and learning from each other (i.e., unit or clinic meetings and celebrations of individual and group accomplishments). Through CoPs, members may accomplish the following: problem solve; request and share information; coordinate and synergize efforts; identify gaps and map knowledge to their particular subject matter; and grow self-confidence in personal skills as one learns from another (Wenger & Wenger-Traynor, 2015).
Due to the characteristics of CoPs and the inherent nature of members to develop and expand nursing knowledge and praxis, the shared governance framework transitioned from a blended administrative-councilor structure to a more congressional model. The centralized councilor structure had designated clinician representatives. The separate councils were useful in addressing issues of broad concern but was not perceived to be effective at the care team level.
The formation of CoPs in the new shared governance structure arose from the natural relationships within the nursing units and clinics. Each unit and clinic within the healthcare system developed its own CoP with a board chair, co-chair, and representatives elected by its members. A representative from each CoP gathers within a larger group called the pavilion nurse clinician council (PNCC). Annually, members from the PNCC, along with hospital executive nursing leaders meet during the system nurse clinician congress. During CoP meetings, members discuss nursing practice concerns (e.g., clinical standards), professional development issues (e.g., specialty certification), and patient care processes (e.g., nurse-sensitive quality metrics). Nursing bylaws, which include the decision-making process, drive the new shared governance structure while operational guidelines provide detailed guidance for each system-level nursing committee and council.
Community of Practice Impact on Professional Practice Work Environment
Executive leaders fully supported the creation of CoPs throughout the system since it better engaged leaders at all levels and nurse clinicians in shared decision making. Now in its seventh year of implementation, the CoPs have been integrated into the nurse clinicians’ and leaders’ culture of shared governance. Nurses within their respective CoPs (approximately 54) are more engaged and satisfied with their practice and work environment, as indicated in their participation through various scholarly and professional development activities and positive nurse satisfaction surveys. Regularly conducted evaluations have demonstrated that quality and safety benchmark indicators are routinely met or exceeded. A nursing committee with a clinician majority makes criteria-based staffing decisions and has decision making/communication channels to the CoP Board. Shared governance facilitates professional recognition of nurses through differentiated practice, specialty certification, and special awards celebrations.
The CoP structure has been successful in transforming practice and advancing the organization’s goal of achieving a healthy professional environment while in the pursuit of nursing excellence. The work and commitment of engaged nurses functioning within a healthy professional work environment have been central to the Nursing Department’s achievements. Through the implementation of a CoP-based shared governance structure designed within a comprehensive NPPM, the organization’s professional and practice accomplishments have been validated externally by its redesignation as a Pathway to Excellence institution. Looking forward, nursing leaders are committed to further enhancing the unique CoP role as a "secret weapon" to pursuing strategic initiatives relative to Magnet Recognition.