Nurses at the bed- or chairside are knowledgeable about clinical and operational concerns that need improvement and, consequently, are in the best position to generate and evaluate practical options and potential solutions to improve efficacy and care processes. Implementation of a shared governance model is effective in engaging staff nurses to make meaningful and sustainable change in patient care processes.
Traditional clinical and operational improvements in hospital and outpatient settings have been led by administrators. This is contrary to the shared governance model in nursing (Bretschneider, Eckhardt, Glenn-West, Green-Smolenski, & Richardson, 2010) and the report The Future of Nursing: Leading Change, Advancing Health (Institute of Medicine [IOM], 2010). The shared governance model endorses a partnership between nursing leaders and direct care staff that promotes collaboration, shared decision making, and accountability for improving patient care and safety (Bretschneider et al., 2010), whereas the IOM (2010) report recommends expanding and promoting opportunities for nurses to lead, design, and implement changes in healthcare delivery systems. Nurses are ideally positioned to enhance efficacy and patient care processes.
Memorial Sloan Kettering Cancer Center, a National Cancer Institute–designated comprehensive cancer center in New York, New York, has an urban outpatient facility with five decentralized infusion units, each providing chemotherapy and supportive care to patients with various types of cancer. Three teams of nurses, each with its own nurse leader, staffed the five units. In 2014, following a year of unexpected and exponential increases in patient volume, clinical and operational challenges (e.g., inconsistent use of treatment space, uneven distribution of nursing staff, lack of communication among unit staff, development of disparate unit cultures and workload expectations) became apparent. Nursing leadership saw the need to combine the staff and management of the five infusion units with the goal of improving safety, efficiency, and cost effectiveness through better use of physical and human resources. One nurse leader was assigned responsibility for the five units, with a staff of more than 70 nurses caring for 300 patients per day in the 62 individual treatment bays. A priority for the nurse leader was to implement a system that would allow the newly merged group of nurses to collaboratively address patients’ needs in the moment and support one another throughout the process, a departure from past behavior.
The nurse leader, serving as the project’s sponsor, acquired institutional stakeholder support and collaborated with the organization’s Learning and Organizational Development (LOD) division of Human Resources to develop a shared governance project. The project would empower oncology nurses to lead change necessary to develop a new, more effective, and sustainable nursing team while improving the care and experience of their patients. An interdisciplinary shared governance model provided the framework for the project team. Project members were a clinical nurse representative from each unit, a clinical nurse specialist, an administrative supervisor, and two LOD specialists. The nurses were selected based on their previously demonstrated leadership ability and willingness to participate. The expected outcome was that this project team would emerge as a cohesive leadership group with patients as its primary focus. The group of nine started with a kickoff meeting during which the goal was described and nursing leadership charged the group members to use innovative thinking and their clinical expertise to influence operational change. The only rule was to keep solutions within budgetary limits. After completing the kickoff day, the group members appropriately named the project “One Mission Coalition” because they sought to bring five teams together to meet a common goal.
The first undertaking was to describe in detail the current state of the clinical environment, including staff assignments, workflow, and standard operating procedures. The next step was to design the ideal future state. Once the future was envisioned, the team members brainstormed ideas that would bridge the gap. Because empty treatment chairs were frequently available in some units, whereas other units were full and had patients waiting, the group focused on improving consistent and equal use of space and capacity, setting a goal of reducing the backlog of afternoon patients by 50%. The group members met weekly during work hours for nine months to assess, plan, implement, and evaluate interventions related to their goal. The shared governance model guided the participants in representing their respective units and engaging their colleagues with regular updates during staff and unit-based meetings and during informal discussions. Anonymous suggestion boxes, email correspondence, and paper and electronic surveys were used to ensure that staff were engaged and had methods of providing input and feedback.
The LOD specialists provided invaluable guidance and a structured format for the nurses who were inexperienced with a project of this kind. They supported the team’s leadership development by coaching to facilitate meetings, communicate effectively, resolve conflict, and negotiate strategies. The nurses learned basic meeting management skills by scheduling sessions, planning agendas, recording meeting minutes, prioritizing tasks, and developing timelines and due dates. As the sponsor, the nurse leader met monthly with the group to receive status updates and provide feedback, encouragement, and support. The group also reported back to the director of outpatient nursing, a key institutional stakeholder.
Although the team did not meet its goal of reducing the afternoon backlog of patients by 50% by January 1, 2015, several positive outcomes emerged. The experience of using a shared governance framework enabled the development of a cohesive and effective team that had a beneficial and lasting impact on the entire nursing staff. In addition, the groups’ recommendations resulted in many operational improvements. As a result of their analysis of chair use, the project team members proposed modifying all nurses’ schedules to 12-hour shifts (others were 10-hour shifts) to provide more consistent clinical coverage. Their thoughtful and substantive rationale and anticipated outcomes for improving patient care convinced nursing leadership of the value of this change despite the budgetary impact from hiring more nurses. This outcome improved the team members’ confidence in their ability to effect change and increased their credibility with their colleagues.
The success of the initial project team and the related skill development, improved communication and collaboration, and culture change among the unit nurses led to the expansion of additional improvement projects. To ensure that the next project team could build on the first team’s success, a structured hand-off from the first team was planned for the second team’s kickoff meeting. Members of the first team shared their goal, strategies, experiences, and lessons learned. This hand-off tactic was instrumental in setting high standards for the next group and provided its members with an operational model. Over time, the teams became more collaborative and inclusive. Membership was expanded to include a second nurse from the largest of the five units and frontline clerical staff colleagues. These new members added a unique perspective and a wealth of expertise that became valuable when discussing operational change. Three cohorts have participated in the One Mission Coalition project to date, with two cohorts completing projects. Summer vacations and short staffing have stalled progress of the third cohort, whose goal deadline was September 2016. Each cohort selects a motivational name to represent and distinguish itself from the other cohorts. Goals and highlights from the work of each cohort are described in Figure 1. The second cohort’s project to create an outpatient charge nurse exchange program was successful in meeting goals and was accepted for a podium presentation at the Oncology Nursing Society 41st Annual Congress in 2016 and the institution’s annual performance improvement fair in 2016.
Many enhancements in the clinical area have occurred since the merger of the infusion units and initiation of the projects. In conjunction with multidisciplinary initiatives with pharmacy and administration, the teams’ efforts have had a lasting impact in the infusion units and created a legacy worthy of recognition, most notably an overall 34% reduction in chemotherapy wait times, from an average of 50 minutes in 2013 to 34 minutes in 2016. In addition, nursing satisfaction scores measured using the National Database of Nursing Quality IndicatorsTM exceeded the benchmark and showed significant increase in 2013 versus 2015 scores in the categories of professional development opportunity and RN–RN interactions. The transition from 10-hour to 12-hour shifts greatly improved nursing staff satisfaction; nurses reported an enhanced sense of teamwork across all infusion units with a positive culture change. Many nurses have developed greater expertise across various diseases, treatment regimens, protocols, and drugs because they care for patients outside of their assigned disease management–based team. Other stakeholders (e.g., hospital administrators, medical oncologists) were pleased because the shared resources allow for more flexibility in patient scheduling for chemotherapy and, most importantly, a decrease in overall patient wait times.
The shared governance model is effective in engaging staff nurses to make meaningful and sustainable change in patient care processes. As illustrated, the project team method can be replicated in any clinical setting undergoing change or restructuring or in need of operational and clinical improvements. The benefits to the staff include learning new skills, acquiring more confidence, and feeling satisfaction from accomplishing a goal and meeting a challenge. In today’s healthcare environment, nurse leaders are often assigned to manage a large portfolio, making mentoring, coaching, and preparing future nurse leaders difficult. Oncology leaders in particular face the challenge of maintaining staff competence with the rapid advances in current cancer care. A shared governance framework provides for structured clinical problem solving while building leadership competencies. These clinical bedside leaders assist with goal achievement on the unit and add to a pipeline of leaders for succession planning. Projects such as this facilitate the preparation of future nursing leaders for patient care and for managerial roles. Increasing the opportunities for staff nurses to initiate change through the cultivation of a shared governance project is an excellent way for nursing leaders to manage and create meaningful and successful change.
The author gratefully acknowledges the project participants, chemotherapy nursing staff, learning and organizational development consultants, and nursing and administrative leadership for their support and participation in this project.
Bretschneider, J., Eckhardt, I., Glenn-West, R., Green-Smolenski, J., & Richardson, C. (2010). Strengthening the voice of the clinical nurse: The design and implementation of a shared governance model. Nursing Administration Quarterly, 34, 41–48. doi:10.1097/NAQ.0b013e3181c95f5e
Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from http://bit.ly/1Y8VcVD
Gordon is an outpatient nurse leader at Memorial Sloan Kettering Cancer Center in New York, NY. No financial relationships to disclose. Gordon can be reached at email@example.com, with copy to editor at ONFEditor@ons.org.