Early in 2006, nurses at Pella Regional Health Center (PRHC), a nonprofit 25-bed, critical-access hospital in rural Iowa, began the journey to attain a higher level of professionalism. On this journey—whose ultimate goal is to earn Magnet® recognition—the nursing staff have gained confidence and autonomy, experiencing a metamorphosis as a collaborative shared decision-making model was implemented.
Working together, PRHC’s Chief Nursing Officer (CNO) Yvonne O’Brien and this author (RN Special Projects Coordinator) charted the course for our destination and determined what would be needed to create the “travel plan” for our journey. O’Brien shared the travel plan with nurse leaders, emphasizing it would take us on the path to a sustained culture of excellence. Supporting the plan was our “road map”—PRHC’s nursing vision and philosophy—as well as process improvement principles based on “lean” health care (which focuses on reducing waste and promoting quality). The travel plan, road map, and process-improvement principles would help us steer a smoother course toward achieving and sustaining the culture changes that would create a higher level of professionalism among our nurses.
Like all travelers, those embarking on the Magnet journey must know the best route to take. But first, we needed to promote certain concepts to gain administrators’ and nurses’ trust and help them buy into the desired culture change.
As part of their planning and research, the nurse leaders studied Diana Swihart’s book Shared Governance: A Practical Approach to Reshaping Professional Nursing Practice. Swihart defines shared governance as “an evidence-based management model of shared decision-making based on the principles of partnership, equity, accountability and ownership at the point of service.”
This definition, in conjunction with PRHC’s nursing philosophy statement (which takes a holistic view of the patient and family) helped nursing leaders determine how to put the new model into action. They researched best practices and national benchmarking to improve quality outcomes. They trained nursing staff on the use of lean healthcare principles to help them eliminate waste in their practice. In addition, nurses got involved in development of an electronic documentation system to enhance patient safety and information sharing across the continuum of care.
The first stop
The first scheduled stop on the trip was an offsite work day, during which nurse managers received the tools necessary to complete the journey—including research materials on the shared decision-making concept, information on eliminating waste and increasing efficiency, and suggestions on building bridges for interdisciplinary collaboration. They also received project tracking forms, to be used by the three inaugural councils that would be established.
A steering committee was formed. It included the CNO, this author, the nurse managers and other nurses who’d been identified as strong leaders with a passion for promoting the nursing profession in the rural setting, and the nurses who would become chairpersons for the inaugural councils. Once the steering committee helped develop the shared governance model, it launched the three councils—quality council, professional development council, and practice council.
In November 2006, PRHC held special events to increase staff nurses’ knowledge and understanding of the shared governance model. A kickoff celebration was scheduled around mealtimes to promote attendance. During the celebration, the steering committee performed a skit with a Star Trek theme (“Shared Governance: The Final Frontier”), because PRHC nurses planned to boldly go where no PRHC nurse had gone before—to the “land” of Magnet recognition.
During the skit, an announcement was made about launching the three councils, which they called the “Starship PRHC.” The mission of the “Starship” included getting nurses to explore the use of new nursing models and nurse empowerment.
A guest speaker gave an overview of shared governance and described how to launch the councils. She gave examples of typical council agendas and encouraged nurses to get involved with council activities. She also gave advice on how to select quality indicators and monitor nursing outcomes.
Engaging the nursing staff
The kickoff event excited the nurses, boosted their engagement in the Magnet journey, and helped them better understand the goal. Each nursing department elected representatives to the three councils. According to Swihart, reassurance may be needed at this time to help staff resolve anger stemming from proposed culture changes. Steering committee members provided support for nurse managers to help staff deal with anger, anxiety, and resistance.
Implementing the three councils was crucial to achieving a shared governance model at PRHC. Council chairpersons were selected, and received guidance to help them understand their role, as well as training on how to conduct meetings, set agendas, write minutes, conduct basic research, and critique articles.
Once all three councils were up and running, their chairpersons attended the steering committee meetings. At that point, the steering committee was renamed the management council.
Over the next few years, as council projects were implemented, council members demonstrated a greater sense of ownership for their practice. Involvement in council activities has helped staff recognize the benefits nurses can gain by being involved in nursing practice decisions. (See Successful council projects by clicking on the PDF icon above.)
Professional development council activities
The professional development council promoted nurse empowerment by calling for nursing stories and testimonies from staff about their practice experiences. Council members compiled the stories into a book.
The council also distributed packets promoting continued education and certification in nursing specialties. Since launch of the councils, the number of certified nurses in PRHC has grown from five to 30. Many rural nurses graduate with a 2-year nursing degree; at PRHC, several have returned to school to complete their BSNs.
Quality council projects
Projects undertaken by the quality council have contributed to increased job satisfaction among nurses. The projects include:
- a hand hygiene campaign, which yielded a compliance score exceeding 90%
- medication error monitoring, with feedback given to individual nurses involved in errors
- activation of a rapid response team
- hypoglycemic protocols
- standing orders for patients with diabetic ketoacidosis.
Greater ownership and accountability
Council members have promoted professionalism among PRHC nurses, which has led to an increased sense of ownership and accountability for their practice. As the councils evolved, a realignment of nursing practice authority occurred, bringing nursing to the center of the shared governance system where nurses have a greater voice.
Over time, council members realized the value of using a collaborative approach for projects affecting patient care. When the quality council was launched, staff nurses began working within their departments to identify appropriate quality indicators along with the use of “lean” processes to eliminate waste and foster performance improvement where needed.
Since implementation of the shared governance model, nursing has received greater support from other disciplines, including speech, physical, and occupational therapies; pharmacy; respiratory therapy; medical imaging and services; environmental services; and dietary services. Each council uses the expertise of members from these departments to bring positive changes. For instance:
- physicians, pharmacists, and dietitians collaborated to develop hypoglycemic protocols
- medical imaging, rehabilitation therapy, and respiratory therapy staff were involved in the handoff communications project.To help maintain and support the work, unit champions have worked to improve collaborative efforts among staff members and departments.
Living the philosophy of nursing
With the collaborative shared governance model in place, PRHC nurses have been living the philosophy of nursing.
They’ve attained a higher level of influence over their practice, challenging themselves to rise to the next level. Many have shown dedication to their specialty by becoming certified and enrolling in RN-BSN completion programs. Several have been awarded special recognition among “100 Great Nurses” by the Iowa Organization of Nurse Leaders.
PRHC nurses now have a new destination—the Pathway to Excellence® program. The American Nurses Credentialing Center (ANCC) created this program to promote nursing excellence in organizations of all sizes. A second kickoff event held in April 2008 introduced nurses to the fundamentals of ANCC’s Magnet Recognition Program®. Ultimately, the Pathway to Excellence program will serve as a bridge toward Magnet recognition—our final destination.
Ronda Reimer is RN Special Projects Coordinator at Pella Regional Health Center in southern Iowa.