SHARED

GOVERNANCE
Giving nurses a voice in their practice

The System of Care: CareTouch

Peer Feedback

Standardized
Documentation

Core Values

Care Teams

Enhanced
Communication
Patient-Family
Centered Care

Capability
Building

Skill Building

Talent
Management

Leader Development
Healthy
Work
Environments
Shared Accountability

EvidenceBased
Optimized Performance
Clinical Inquiry Centers

WHAT IS SHARED GOVERNANCE?

Shared Governance gives nursing team members a voice in

their practice and the innovation of that practice through

elected nursing practice councils at unit, facility, region, and
ANC levels
Shared Governance:
Creates a structure to implement practice guidelines
Provides a framework for professional accountability
Recognizes staff nurse's authority and responsibility for their practice
Promotes nurses voices in their practice
Improves functioning: Substantial literature and experience indicates
that Shared Governance

- Increases nurse engagement

- Improves the working environment

- Improves the quality of care provided

What is Shared Governance?

Shared governance means that as nursing staff, you are given

A mechanism for implementing practice guidelines on your

unit

A voice in innovating your practice

An easy pathway for sharing concerns and ideas with

management

Accountability for all issues elating to nursing practice

Representation for bedside nurses at the executive level of

the Department of Nursing

Empowerment to translate ideas into actions

How do we achieve it?

Your unit will form a Unit Practice Council (UPC), which will
include:

Members representative of the unit (all positions, active duty and

civilian)

An election based on individuals who self-nominate for the UPC

A UPC Chair, Co-Chair, Secretary, and Facility Nursing Practice
Council rep

GOALS OF SHARED GOVERNANCE

Shared Governance provides a framework for encouraging

professional accountability

Goals
Implement practice innovations,
including clinical practice
guidelines and quick wins
supported by peer-reviewed
literature and other evidence
Increase nurse autonomy by
giving nursing team members a
voice in their daily practice and
the innovation of that practice
Drive and tailor ANSOC
implementation, sustainment,
and refinement on the unit

Impact
Evidence-based practice
innovation, nurse autonomy,
and successful ANSOC
implementation that is
relevant and appropriate for
the unit

BENEFITS OF SHARED
GOVERNANCE
Benefits to
unit staff

Benefits to
facility

Allows innovations to get visibility and support from facility-level

leadership
Shares ideas across units
Helps leadership identify when unit struggles actually have a
system-wide basis, and helps proactively address these

Results in significant improvement in nurse engagement

Increases satisfaction with the work environment

Improves nurse perception of autonomy
Results in lower nurse turnover (documented rates of <10%)
Decreases nurse absenteeism (documented rates of 0-5%)
A part of achieving Magnet status; part of Pathways to Excellence
Widely adopted among top nursing practices and best-in-class
healthcare facilities
Benefits described by peer-reviewed
literature listed in the Appendix

HOW THE UPC AND CNOIC/NCOIC

WILL WORK TOGETHER
CNOIC/NCOIC will turn to UPC as decider on key practice

related issues within their primary scope

CNOIC.NCOIC will concur or in rare cases, veto (see slide 10)
UPC will need guidance from CNOIC/NCOIC for both practicerelated issues and ANSOC implementation:
Practice-related issues: UPC will want input on quick wins and
practice innovations, including ideas for both, feasibility,
priority and required next steps
ANSOC implementation: UPC will need consultation on
tailoring of ANSOC components

ACCOUNTABILITIES FOR SHARED DECISIONMAKING

Management
Clinical Practice Accountabilities
Accountabilities
Standards of Practice
Resources/Allocation
Specialty and related
Human
Clinical competency
Fiscal
Care Delivery Model
Shared
Material
Professional Development
Decision Structure
Orientation
System/Organization
Continuing education Making
al Links
Certification
Reward and
Advanced degrees
Recognition (from
Quality
continual
EBNP
performance
Research
evaluation)
Outcomes
Peer Review
Interdisciplinary Relationships

EXAMPLES OF HOW OTHER UNITS HAVE

IMPLEMENTED SHARED GOVERNANCE (1 OF 3)
Preventing infection

Streamlining a procedure

Setting a name tag trend

An Inpatient Med/Surg UPC

Combined surgical suite UPC

Another inpatient Med/Surg

identified several issues with

wearing ACUs on the floor:
The long sleeves had
significant potential to act
as a vector for germs
The need to wash the ACUs
daily was quickly wearing
them out, and they were
expensive to replace
The UPCs proposal to their
CNOIC recommended the use
of short-sleeve scrubs for
military nurses and provided
evidence that the proposed
change would both reduce the
chance of spreading infections
and the cost of uniforms
Due to the UPCs evidencebased recommendation, the
uniform was changed to
optional scrubs for all nurses
on the unit

brought voices of nurses from

separate but highly
interlinked groups together
for the first time
Suggestion from OR nurses
requested that the pre-op
nurses put on a specific type
of immobilization before
anesthesia
The UPC immediately worked
to ensure that pre-op nurses
could change a simple
procedure to make OR nurses
jobs easier

UPC heard that patients were

confused about the roles of
the various nursing team
members
The UPC proposed an
initiative to have name tags
with nurse roles on them
The tags were a hit and
spread to the doctors in the
unit, and from there were
adopted around the facility
because of their popularity

EXAMPLES OF HOW OTHER UNITS HAVE

IMPLEMENTED SHARED GOVERNANCE (2 OF 3)
Hand hygiene

The nursing team of an adult

medicine clinic noticed that

patients did not wash their
hands frequently when at the
hospital
The UPC brainstormed ways to
effectively increase hand
hygiene
The UPC proposed mounting
Purell dispensers in the
hallways to encourage everyone
to have better hand hygiene
The UPCs recommendation is
in line with evidence on
infection control and frequency
of use with different kinds of
hand hygiene
The CNOIC accepted the
proposal and dispensers were
mounted on the walls

Streamlining a procedure

A Hem/Onc clinic and an inpatient

unit wanted to optimize their

coordination of care
They identified three areas to
improve: communicating more
often, communicating more
effectively, and becoming more
familiar with the other units
operations
The clinic staff began providing a
patients last lab, pharmacy flow
sheets, and oncologist note to the
inpatient nursing team
The inpatient units Lead RNs
began calling down to the
Hem/Onc clinic to speak with their
patients team to ensure that the
inpatient plan of care was
congruent with the outpatient plan
of care
The UPCs invited each other to
various events (e.g., BBQ, after
hours event) to increase
collegiality between the units

Surgical tours

An OR unit and a PACU

realized that patients and their

families got very anxious before
a surgery
To reduce their patients
anxiety, the UPCs collaborated
to hold a monthly surgery tour
where the patients and their
families could get familiar with
the rooms and what would
happen during care
This allowed patients and their
families to better plan for the
surgery and recovery; it also laid
the groundwork for a culture of
trust and communication
between the patients, families,
and staff
The concept was so successful
and popular that the PAO did an
article on the concept

EXAMPLES OF HOW OTHER UNITS HAVE

IMPLEMENTED SHARED GOVERNANCE (3 OF 3)
Fall prevention

Two inpatient med/surg units

wanted to prevent falls

Their UPCs decided to have a
competition for who could go
longer without any falls
The units put up posters
indicating the number of days
since their last fall
Each reviewed best practices on
falls prevention and instituted
the methods they felt would help
their unit most
Falls decreased dramatically
over the months of the
competition and stayed low
The staff became actively and
creatively engaged in preventing
falls through friendly
competition

Streamlining a procedure

A GI unit and PACU at a

MEDCEN wanted to optimize their

coordination of care
The units had a good record of
communication and wanted to
ensure this trend continued
The units modified an existing
documentation form to accurately
reflect changes in their practice,
familiarized staff through inservices, and monitored compliance
through chart audits
In addition, the units set three
goals:
GI staff would perform
accurate and complete bed
side hand-off communication
to PACU staff
PACU discharge criteria would
be met prior to initiation of
report call to the GI unit
PACU staff would call report
to a licensed GI staff member
prior to release from PACU

Minimizing need for ABGs

The adult critical care and

respiratory care units identified

that new clinical guidelines called
for use of PetCO2 (capnography)
in several new patient
populations
The nursing staff developed a
recommendation to routinely use
PetCO2 monitoring on patients
receiving moderate sedation and
those at risk for respiratory
compromise, in addition to
intubated patients (who already
were routinely monitored with
PetCO2)
The nursing staff engaged their
leadership, CNS, providers, and
respiratory therapists to properly
implement the change and track
its impact (e.g., reduction in
ABGs)
They instituted hands-on training
with a goal of making PetCO2
monitoring part of their daily
best practice

ESTABLISHING REPRESENTATIVE
UPCS

Guidelines

Representation
The ratio of nursing roles on the UPC should mimic that of the unit (i.e., % of RNs, LPNs,
CNAs, civilian, and military staff on UPC is reflective of mix on the unit)
Each member has a constituency they talk to before each meeting and update after
Constituencies may be assigned, based on who elected them, or based on another model
Nomination
Individuals can self-nominate or be nominated by others
In small units, everyone may be on the ballot automatically unless they opt out
Size
Ideal size of UPC is 5-15 members; each member should have ~4-7 constituents
Some units may combine to form a council
Terms
UPC members serve 1-2 years before re-election
Lessons Learned
Members in good standing can be reelected
Representatives must be able to update all
Members roll on and off at different times for
their constituents personally therefore
continuity and institutional memory
representatives should have no more than
Limiting number of consecutive terms to two
seven constituents
can help most of the staff to serve over the
At Tripler, some UPCs decided all elections

years, facilitating buy-in

would be in January of every year; what
Election rhythm:
they found was that the new UPC was all
If a UPC decides on 1 year terms, half the
new members and no one knew how to run
positions are up for re-election every 6 months
the meeting or what had been done before.
If a UPC decides on 2 year terms, half the
When they staggered elections, new
positions are up for re-election every 12
members learned from their predecessors
months

QUICK WINS
Quick wins should be

Something everyone can get excited

about
Concrete, easy to put your hands on
Rapidly accomplishable
Non-controversial
Able to make a daily difference
Recommendation
Focus on only 1-2
quick wins at a time

For each quick win, identify

The goal/proposal

Data supporting that the goal is a

good one

Data suggesting that this is the

appropriate method to address the
goal

Steps required to get to that goal

The rationale and reasons for the

goal

Who you need to win over

What information you need to
collect

Possible challenges and ways to

address those challenges

Backup option/goal
Leader(s) who will own the proposal
Resources the leader(s) can use

UPC COLLABORATION WITH OTHER

GROUPS

The UPC works with other people and groups at both the unit and facility levels
CNOIC/NCOIC: The UPC identifies and prioritizes quick wins and long term goals and
ANSOC tailoring in conjunction with the CNOIC/NCOIC
Unit nursing team: A project board and/or website are updated every meeting and track
outcomes of UPC projects for all to see
Guests: The UPC invites guests to sit in on meetings as relevant for problem solving, e.g.,
pharmacy, hospital services
Facility NPC:
UPCs each elect a representative to the Facility NPC
UPCs present updates and innovations to Facility NPC monthly

Autonomy of the UPC

Each UPC is self-governing, e.g., deciding for itself how it will conduct meetings and breaks,
schedule rooms, develop norms under its charter etc
UPCs must still work within unit norms and with the CNOIC/NCOIC

Guidelines

Lessons Learned
Some CNOIC/NCOICs were concerned that they might
not know what changes were happening in the unit or
be able to share key insights, so the Facility NPC
developed a set of guidelines for all UPCs to ensure
that CNOIC/NCOICs kept informed of progress and
had clear channels for providing input and feedback

: EXPECTATIONS FOR UPC

ATTENDANCE AND ROLES
Guidelines

Attendance
Each UPC representative is required to attend each meeting. Staff are not scheduled on
the floor during meetings. Missing meetings requires an official excuse (must have
annual, military, or sick leave)
The charter should specify how to deal with members who miss meetings repeatedly

Roles
There is a Chair, Co-chair and a Secretary
The Chair, Co-chair and Coach solidify the agendas and meet with the

CNOIC/NCOIC before each meeting

The Secretary takes and publically posts minutes and keeps the UPC on track for
due-outs
These roles are decided at the first meeting
Lessons Learned
One facility found that if all their UPCs met on a
single day each month, it was easier to predict,
schedule for, and reserve rooms. Attendance was
boosted by holding all the meetings on one day; For
other facilities, covering the ward with so many
nurses out or finding rooms for all UPCs may be
hard

RESOURCING UPCS
Guidelines

Time:
Dedicated time for introducing nursing team to UPC and training those

involved with the UPC

Dedicated time for members to attend meetings
Early in the process: In order to get traction against the issues required
for the first months UPCs will likely need to meet for 2 hours once or twice
weekly
Steady state: UPCs will meet for ~1 hour monthly1
Members should not be pulled away during meetings
Dedicated time for Coaches to prepare for meetings, attend and coach
Dedicated time for Unit Shared Governance Leader/UPC Chair for training
and pushing forward initiatives
Materials:
Lessons Learned
UPCs need access to:
One facility found that using a meeting space
Bulletin board
in a different part of the facility, away from the
Room for meetings
unit, increased the efficiency of meetings
because it reduced distractions and the
Other materials, e.g.:
number of times the UPC members were
- Email
interrupted with issues on the floor
- Poster supplies
- Access to AKO

1 Some UPCs may meet 2 hours per month or arrange time in other fashions

WILL THE UPC BE REQUIRED TO MAKE

TOUGH DECISIONS?

Unit members will bring issues and recommended

solutions to their UPC

The UPC will not make decisions in a vacuum they will
receive input and guidance from unit leaders, the Facility
NPC, and others as appropriate
The UPC will develop evidence-based
recommendations/proposals to give to unit leadership
and staff
Everyone will be a part of the decision making process

HOW WILL MY VOICE BE HEARD IF IM NOT

ON THE UPC?

Every staff member on your unit will be assigned a

member of the UPC as their rep (most UPC members

will be the rep for 4-6 constituents)
Each UPC member is responsible for keeping their
constituents updated on the issues being discussed by
the UPC and getting their feedback
UPC members should have face-to-face contact with their
constituents before and after each meeting

WHATS THE DECISION-MAKING PROCESS

FOR THE UPC?
The UPC will decide how it makes decisions and

recommendations either through consensus or voting or

both
When making decisions, each UPC member will provide
their recommendation based on the input of their
constituents
Additionally, the UPC will take into account any guidance
unit leadership may have provided
Do not take it personally if your recommendation is not the
final outcome everyone has the opportunity to let their
voices be heard, and the UPC will make the decision they
believe is best for the entire unit
The UPC also has the ability to try a course of action, then
go back to re-evaluate and change directions based on
results and continued feedback

WILL THE UPC WILL COME UP WITH IDEAS

THAT WILL CHANGE LONG TIME ROUTINES?

The short answer is Yes

The UPC is designed to be an avenue for evidence-based

practice innovation within the unit, so it is quite possible

that it will come up with ideas that may change long
time routines
Decisions will be made based on current research and
clinical evidence, clinical practice guidelines, best
practices, etc.
All changes should be driven by the goals of enhancing
the quality of nursing care, improving patient outcomes,
satisfaction, and/or experience, and creating a healthy
work environment for our team

WILL YOUNG NURSES CHANGE THINGS

WITHOUT THE BENEFIT OF EXPERIENCE?

It is critical that the UPC membership is representative

of all staff members on the unit, including both

experienced and less-experienced nursing staff
Whether the experienced staff are UPC members or
constituents, everyone has an equal voice through their
UPC rep and the insight of experience from long time
staff will be taken into consideration
Young nurses are also helpful to have on the UPC
because they are often closest to recent updates to
nursing practice and can bring a fresh perspective and
enthusiasm to the work area
All UPC decisions are made after consulting all members
of the unit and considering everyones ideas and
perspectives

WILL MILITARY CONCERNS WILL TRUMP

CIVILIAN CONCERNS?

Every staff member (military or civilian) has an equal

voice on the UPC

Both military and civilian nurses have particular
constraints and interests that should be considered
equally in any decision-making process
However, UPCs have some limits on the
recommendations/decisions they can make there may
be some issues more appropriately addressed by unit
leadership
The UPC Chair and Co-chair can work with their UPC
Coach and unit leadership to identify those concerns best
dealt with through the UPC and those that should fall
under the purview of the units chain of command

WITH THE RANK STRUCTURE OF THE MILITARY,

WILL SOME UPC MEMBERS BE INTIMIDATED IN
LETTING THEIR VOICES BE HEARD?

Within a UPC, EVERYONE has an equal voice

regardless of rank, experience, or education level

There should be a representative of almost all staff types
within your work environment (RN, LPN, NA, medic,
clerk, tech), as well as a mix of civilian and military

WHAT IS THE ROLE OF THE CNOIC AND

NCOIC IN THE UPC?
Unit leadership has a significant role in unit Shared

Governance, including to:

Provide vision, guidance, coaching and support for your UPC
Provide protected time for your UPC to meet
Maintain dialogue with the UPC while empowering them to

come up with recommendations enhancing the quality of

nursing care, improving patient outcomes, satisfaction, and/or
experience, and creating a healthy work environment for the
team
Give the UPC opportunities to update staff during staff
meetings

It may be helpful for unit leadership to join the UPC

meeting (preferably toward the end of the meeting) so

that the UPC can provide updates, ask questions, and get
unit leadership guidance and feedback

AS THE CNOIC / NCOIC, WHAT SAY WILL I HAVE IN

THE DECISIONS BROUGHT FORTH BY THE UPC?

Your roles as the leaders of the unit are unchanged

You provide the vision, guidance, and parameters for the

UPC to move forward on ideas and projects

Your leadership challenge is to identify ways to collaborate
with the UPC and give them as much responsibility as
possible while still maintaining proper command and control
this will take some work by both the unit leadership and
the UPC to figure out a process that works for the team
The UPC has the authority to come up with ideas, do the
research related to those ideas, and formulate
recommendations
Depending on the topic, the UPC must then go back to unit
leadership and/their constituents for final authorization or to
get the issue elevated to a higher level (for example, the
Facility NPC)

I FEEL THE UPC HAS TO DO WHAT I SAY BECAUSE I

AM THE BOSS. IT THAT RIGHT UNDER THIS MODEL?

The whole point of shared governance is to empower staff

members to become part of the solution, so they feel like their

voice is being heard and they are invested in the success of the
unit (this is a change in philosophy from the previous way that
the Army has practiced)
The UPC should have the freedom to brainstorm evidence-based
solutions to issues that enhance the quality of nursing care,
improve patient outcomes, satisfaction, and/or experience, and
create a health work environment for the team (see scope of focus)
Unit leadership should work collaboratively to implement those
solutions that make sense and coach the UPC on how to
improve/refine recommendations that are not feasible as
submitted
When possible, unit leaders should include their UPC in solution
development it can actually significantly reduce leadership
workload