Fall 2005

Over the past few decades, the concept of shared governance has been broadly generated across the health-care system. Both the concept and practice has provided the foundation for a professional organizational framework for the practice of nursing. And yet, many still doubt the validity and veracity of shared governance as a legitimate organizational framework for the professional practice of nursing. While shared governance has stood the test of time, there are still a number of nursing leaders who fail to recognize the value of shared governance in professional decision-making and for its use in operationalizing the organization in a way that supports professional practice. As a result, whether intended or not, these leaders often move nursing organizations into a vertical dependency structure which is not inherently supportive of the profession of nursing nor does it establish practitioner ownership of clinical work (Porter-O'Grady, 2001). What is often tragic in this consideration is that these very leaders unwittingly impede the profession of nursing from moving fully to express its professional role and slows developing the professional staff in a way that expresses their own ownership and engagement of their professional practice (Wood & Winston, 2005). These leaders do this in a number of ways.

Some nurse leaders keep their staff from having the power they need to make decisions and continually keep them from getting it. The most dangerous and insidious leadership behaviors is the aggregation of power in the hands of these leaders at the expense of distributed power in the hands of the professional staff (Wrzesniewski & Dutton, 2001). Many of these leaders have worked diligently to become skilled and talented in the management and use of their own power. The problem is however, all along the way they have failed to realize that the stronger they become in terms of the aggregation and use of power, the less that power is distributed equitably throughout the profession. In nursing and other arenas, this unilateral expression of power on the part of administrators and managers almost certainly guarantees inadequate distribution of power between and among staff members. The problem with management aggregated power, even in nursing management, is that it robs the professional from full expression of the power necessary to adapt professional practice to the changing conditions and circumstances that influence it.

Other nurse leaders have developed a high level of codependency in their expression of the role. In the United States we have a tremendous affection for heroes and individual stars (Adair, 2002). The problem with that is that star making often operates at a disadvantage of others and limits embracing others to fully develop their own goals and skills, limiting other’s ability to express leadership in a meaningful and viable way. In a hero culture, the hero often gets the opportunity to fully express, engage, and be rewarded for exceptional skills and leadership. What often happens in this set of circumstances is that this reward doesn't necessarily extend to others outside of the hero. This “cult of personality” approach to heroic leadership limits the organization and the profession in a significant way at the same time that it advances the interest and opportunities of the individual leader who is unilaterally emulated by such behaviors. While the leader may be advantaged, it is the profession and its members who frequently pay the price for this advantage.

In other circumstances, when the individual leader is empowered, the staff often is not. Empowering an individual and allowing that person an opportunity to grow and develop unilaterally often creates a problems with regard to empowering behaviors in a broader context (Mastrangelo, Eddy, & Lorenzet, 2004). If the expectation of a profession is that all its members act in an empowered way, the distribution of power is a critical element of assuring an inclusive pattern of behavior. A part of the challenge in creating a professional frame is clearly distributing the locus of control with regard to specific decision-making. While there clearly is a requisite for managers to be making specific decisions (especially those in relationship to resources) other decisions should fall under the purview of other accountable players (Porter-O'Grady, 2003). The critical element in this distribution of power is locating power in the appropriate place where it can best be fulfilled and executed. In order for this to occur, the accountability for decision-making and the locus of control which assures its appropriate expression must be deliberated and delineated between key players in the nursing organization in a way that assures the most effective frame for decision-making within a professional context.

The need to share power and expand accountability takes us to consideration of shared governance as a vehicle for making decisions and effectively delineating real empowerment in a professional organization (Prince, 1997). The purposes of shared governance is to provide an organizational frame which increases the obligation and opportunity of professional members of the nursing staff to make decisions that affect their work and to be fully involved in implementing and evaluating the effectiveness of those decisions in order to increase professional accountability for them. Building a shared decision-making infrastructure alters the more vertical and parental orientation to organizations that have traditionally been the frame for nursing practice in hospitals and health-care systems. As nurses become more accountable in undertaking and expressing their role in decision-making and taking appropriate action, their sophistication and skill in unfolding it also grows (Stack & Burlington, 2002). The challenge for leaders in the set of circumstances is that as the staff grows in their effectiveness in decision-making, leadership requires a higher level of sophistication and elegance in its expression. One of the challenges that relates to this shift to staff accountability and higher levels of leader sophistication, is that most contemporary nursing managers learned most of what they know about leaders in job related processes (on the job training). As the work changes, jobs change, and roles change within decision-making and staff-directed practice activities, the characteristics of the to the role of leader are also dramatically affected. As a professional matures in decision-making it becomes incumbent upon the manager to refine and raise the level of leadership skill expression in order to continually guide and grow the staff skills toward and more mature adult-to-adult relationship. This is often a significant leadership challenge, but, ultimately is the real work of leadership.

Today, nursing organizational measures of excellence are becoming increasingly important as health care payment structures begin to look more assiduously at competence and performance. As focus on performance engages staff at a higher level of interaction, communication, and expression, staff must become more involved in decisions that affect their practice. In the Magnet Recognition Program, it is becoming increasingly essential that staff indicate a strong sense of professional ownership of their practice and demonstrate increasing levels of involvement in decisions and actions which relate to expression of practice, evaluation of practice, and improvement of clinical impact on patient care (ANCC, 2005). The fact that shared governance is identified as an important element of effective organizational structuring clearly indicates the need to create an infrastructure for excellence that builds into a sustainable organizational framework within which the professional practice of nursing can continuously unfold and grow. However, a key element of this professional maturation is the mature expression of the role of the leader, the engagement of decision-making accountability principles, and the construction of a participating operating infrastructure within the profession (Upenieks, 2003). Furthermore, true shared governance demonstrates a personal ownership on the part of the professional guided by a facilitating and supporting nursing leader that recognizes the need to place decisions as close to the point of the service is possible (Kramer & Schmalenberg, 2004). This requisite in leadership behavior and the major transitions in the expression of leadership skills that are implied in it, is a critical first step in creating an effective professional model of decision-making and the organization necessary to guarantee its sustainability.

Finally, I would submit that it is difficult, if not impossible, to sustain high levels of ownership and investment in the profession by nurses who do its work without a significant changes in leadership behavior that will support the shift in locus of control and professional ownership (Malloch & Porter-O'Grady, 2005). Without making these changes in leadership, and understanding the shift in the expression of leadership roles in creating a context for professional practice, the opportunity for the profession to fully grow in an organization is severely limited. Ultimately it is the staff nurse’s professional accountability, investment and involvement in the activities of the profession, that inexorably leads to the attainment and advancement of higher levels of excellence in patient care.

References

Adair, J. (2002). Understanding Motivation. New York: Kogan-Page.

ANCC. (2005). American Nurses Credentialing Center Magnet Recognition Program: Recognizing excellence in nursing service. Washington, DC.: American Nurses Publishing.

Kramer, M., & Schmalenberg, C. (2004). Magnet hospitals: What makes nurses stay? Nursing, 2004, 34(6), 50-54.

Malloch, K., & Porter-O'Grady, T. (2005). The Quantum Leader: Applications for the new world of work. Boston, MA.: Jones & Bartlett.

Mastrangelo, A., Eddy, e., & Lorenzet, S. (2004). The importance of personal and professional leadership. Leadership & Organization Development Journal 25, 25(5/6), 435-451.

Porter-O'Grady, T. (2001). Is Shared Governance Still Relevant. Journal of Nursing Administration, 31(10), 468-473.

Porter-O'Grady, T. (2003). A different age for leadership, Part 1: New context, new content. Journal of Nursing Administration, 33(2), 105-110.

Prince, S. (1997). Shared Governance: Sharing Power and Opportunity. Journal of Nursing Administration, 27(3), 28-35.

Stack, J., & Burlington, B. (2002). A Stake In the Outcome. New York: Currency Doubleday.

Upenieks, V. (2003). What constitutes effective leadership? . Journal of Nursing Administration, 33(9), 456-467.

Wood, J., & Winston, B. (2005). Toward a new understanding of leader accountability: Defining a critical construct. Journal of Leadership & Organizational Studies, 11(3), 84-94.

Wrzesniewski, A., & Dutton, J. (2001). Crafting a job: Employees as active crafters of their work. Academy of Management Review, 26, 179-201.


 

Tim Porter-O’Grady