A large safety net, academic health care system revised its Shared Governance structure as part of the implementation of a new Nursing Professional Practice Model (NPPM). To advance decision-making engagement, the strategic development team adapted Tannenbaum and Schmidt’s (Dudovskiy, 2013; Tannenbaum & Schmidt, 1973) classic leadership continuum into a clinically-relevant model to facilitate a higher degree of shared decision-making. A research study was initiated to determine registered nurses’ perceptions of using a shared decision model to make practice and professional role decisions. The aim of this qualitative, descriptive study was to infer registered nurses’ (RNs) perceptions of factors that facilitate or impede successful use of the shared model as well as identify notable decision-making patterns based on evidence compiled from interviews. The investigators anticipated that the results of this study, combined with a review of the literature, would serve as a foundation for determining next steps to increase the level of engagement in shared decision-making within the context of shared governance.
Background
In 2011, the nursing department revised its shared governance from a conventional centralized councilor structure to one which incorporated engaging Communities of Practice (CoP) at the unit and service levels. This model focuses on emergent engagement of professionals with a shared purpose and creates a learning community that builds the practice capacity of individuals and the group as a whole. According to Wenger (2015) who described the dynamics of the concept, CoPs are more prevalent in business and education where they have proven to be effective in enhancing performance, employee engagement and satisfaction. Though not commonly seen in healthcare settings, the conditions Wenger identified for creating a CoP are inherent in professional nursing environments: a specific domain of interest/practice, shared purpose and practice functions, and an established professional community. The restructuring process involved identifying naturally occurring CoPs and empowering them to make choices that influence unit- and organizational-level practice and professional decisions.
A shared decision model, based on Tannenbaum and Schmidt’s leadership continuum, was adapted to guide CoP members, administrators and other shared governance participants in determining the level of influence appropriate for clinicians and leaders to exert in making decisions relevant to specific situations. During 2015-2017, this study was conducted with the expectation that the results, combined with a review of the literature, would serve as a foundation for determining next steps to increase the level of engagement in shared decision-making within the context of shared governance.
Literature Summary
Nursing and leadership/management sources were reviewed for an extended timeframe due to the paucity of publications. The search resulted in a dearth of evidence-based structures or guides to facilitate clinician engagement in participative/shared decision-making. Only one nursing source was found that substantiated the value of a specific, defined guide for decision-making in shared governance and reported its impact on clinician decision-making behavior (Recker, Bess & Wellens, 1996). More recent nursing literature focused on studies reflecting the gap between nurses’ preferred versus actual level of involvement in practice and organizational decisions (Gerard, Owens & Oliver, 2016; Havens & Vasey, 2003; Jaafarour & Khani, 2011). Notably, Scherb and colleagues (2011) found a statistically significant disparity between staff nurse and nurse manager perceptions of preferred versus actual decisional involvement; staff nurses perceived they had less decisional involvement than nurse managers perceived they had. Anderson and colleagues (2013) asserted that participative/shared decision-making is a property of complex adaptive systems that emphasizes team decision-making emerging from expertise, substantiating the importance of team decision engagement. Two other studies reported a relationship between the degree of anxiety leaders feel relative to communicating with others (communication apprehension), their willingness to share information, and their propensity for participative decision-making that impacts performance (Lam, Hung & Chan 2015; Russ, 2013). These management studies, taken as a whole, point to the critical role leadership patterns play in facilitating the engagement of clinicians in shared/participative decision-making.
Methodology
A qualitative, descriptive design was used to conduct the study of a volunteer sample of RNs employed by the institution. Each nurse was asked to complete a socio-demographic questionnaire and respond to a semi-structured interview. The foci of the open-ended questions included: knowledge about shared decision-making; type of shared decisions nurses made in their CoP; experience working with a decision-making model; and facilitators and barriers for shared decision-making. Audio recordings were transcribed verbatim and line-by-line examinations were completed by all study investigators. Interviews were conducted until data saturation was achieved. Investigators identified salient response patterns from the data associated with each of the interview questions. Inter-rater congruence and clarification of identified patterns was achieved during team meetings.
Twenty four nurses participated in the study; the majority held roles with some type of leadership responsibility ranging from point-of-service (bedside) leadership to upper middle management, they were highly diverse with a mean of 20 years experience, and 70% held graduate degrees.
Results and Discussion
Salient patterns from the interview responses were used to answer the main study question: “What are registered nurses’ perceptions of using a shared decision model to make practice and professional role decisions?” Study participants expressed a general understanding of shared decision-making though they had not used the shared decision model as a resource. A majority of the participants indicated they thought the model was a good tool and would facilitate shared decision-making. However, participants voiced the need for broad scale education, accessible resource persons, an organization-wide commitment and nursing management reinforcement in order to increase utilization of the decision model.
Seventy-five percent of participants associated shared decision-making with CoP activities. However, most had difficulty in providing clear examples of shared decisions or articulating the professional and practice impact made by those decisions. There were notable variances in participant descriptions of their shared decision-making experiences; some positive and some negative. Managerial behavior was identified as a key determinant in the nature of their experiences.
The stated study aim was to infer from the RNs’ perceptions the influencing factors that facilitate or impede successful use of the shared decision-making model. The following facilitating influences emerged: 1) shared governance framework; 2) active engagement in unit level CoP functions; 3) specialty certification and continuing education; and, 4) CoP engagement in the Clinical Advancement Program. The following impeding influences emerged: 1) hierarchical organizational culture; 2) lack of knowledge regarding shared decision-making model and process; 3) inadequate time and resource commitment to implementing shared decision-making; and, 4) organizational changes disruptive to shared governance and participative decision-making. The nature and level of leadership clearly emerged as the militating influence critical to the actualization of shared decision-making. Inferences made from response patterns indicated that study participants perceived leaders in managerial and clinical roles have the most substantive effect on whether or not nurses actually engage in shared decision-making in their practice environment.
A culture in which staff exhibit shared decision making manifests the principles of shared governance that underpins a professional practice environment (Gerard, Owens & Oliver, 2016). Based on this study’s findings, the most impactful influence on creating such a culture is the nature and extent of leadership guidance, engagement, and support for shared decision-making. Consistent with a number of studies on decisional involvement, participants in this study indicated they desired a higher level of shared decision-making than they actually have had the opportunity to experience.
Implications
Study participants were positively inclined toward using a shared decision model, but identified the need for development strategies to:
- Educate managerial and clinical leaders and all nursing staff included in nursing bylaws on the use of the adopted shared decision model;
- Offer leadership development specifically addressing communication patterns, information-decision making dynamics, and participative decision making engagement;
- Provide time and resources for effective implementation of the shared decision-making model;
- Make an organization-wide commitment to use and reinforce the use of the decision model within the context of the shared governance system; and,
- Promote a shift from a hierarchical to a participative leadership- shared governance culture.
Building and sustaining healthy work environments relies upon true collaboration, effective decision-making and authentic leadership. This study provides a roadmap to support other healthcare organizations in optimizing decision-making processes at all levels of nursing in order to sustain a healthy workplace and promote the delivery of exemplary patient care.