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This project used the Council Health Survey to evaluate the effectiveness of shared governance councils in a children’s hospital during the COVID-19 pandemic. A SWOT analysis was performed to assess the organization’s strengths, weaknesses, opportunities, and threats regarding council health and to inform strategies to sustain the shared governance environment. The well-established shared governance infrastructure allowed the organization to rapidly pivot council operations to sustain nurse engagement while balancing the unprecedented staffing and resource challenges of the pandemic. Organizations must remain flexible and innovative to maintain an environment supportive of nurse empowerment and shared governance during public health emergencies.
Key Points
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An unwavering commitment to shared decision-making may allow organizations to achieve exemplary patient, organizational, and professional outcomes, even when faced with the challenges of the COVID-19 pandemic.
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The Council Health Survey may help organizations assess and optimize council effectiveness, and ultimately, the shared governance environment.
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Virtual technology enhances communication and engagement of clinical nurses during times of crisis.
Shared governance councils are at the core of nurse empowerment and the nurses’ ability to have a voice in decision-making, which enhances patient safety, quality of nursing care delivery, and patient outcomes. Historically, organizations have used the Index of Professional Nursing Governance (IPNG) to measure nurses’ perception of authority, influence, and control over their nursing practice.
However, the IPNG was not designed to measure the effectiveness and efficiency of council operations within the shared governance environment. Therefore, Hess and colleagues
developed the Council Health Survey (CHS) to evaluate the shared decision-making infrastructure that council leaders at both the unit and organizational level may use to optimize council operations and the professional nursing practice environment. It is essential that health care organizations study the microcosm of their councils in order to best understand the macrocosm of their shared governance environment.
Shared Governance at Organization
Arkansas Children's Hospital is a large academic children’s hospital system that serves pediatric and select adult patients on 2 hospital campuses in the central and northwest sections of the state of Arkansas. The Little Rock hospital campus employs approximately 1430 registered nurses, including 282 nurses and 33 interprofessional colleagues engaged in shared decision-making councils.
The formal shared governance model was implemented at Arkansas Children's Hospital over a decade ago. The intended purpose was to provide an organized, nurse-led, interdisciplinary model to achieve the goals of the nursing strategic plan and ensure excellence in patient care. The council structure provides a consistent approach for shared decision-making and serves as a key method for promoting professional nursing practice and patient and family-centered care (Figure 1). The council structure is organized into 5 main categories with varied scope of responsibilities: organizational councils, clinical area-based councils, designated group councils, support councils, and cabinets (Table 1). Bylaws clearly delineate the purpose, function, scope of responsibility, and level of authority of these councils along with the structure of council meetings, process for membership selection, and roles, responsibilities, and expectations of council members.
Figure 1Model of Shared Decision-Making Councils at Arkansas Children's Hospital
Table 1Purpose of Shared Decision-Making Councils at Arkansas Children's Hospital
Specific Council
Scope of Responsibility
Coordinating council
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Provide oversight in achieving nursing excellence by facilitating effective council structure and processes and accomplishment of Arkansas Children's Hospital goals of:
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Professional nursing behaviors
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Safe, high quality care
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Supportive work environments
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Patient, family, and nurse satisfaction
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Staff retention
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Fiscal stability
Organizational council steering committee
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Provide guidance to organizational councils by assisting with issue navigation, direction, and process implementation, and helping to ensure excellent care through achieving outcomes.
Clinical practice organizational council
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Promote consistency of care across the continuum.
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Oversee and recommend changes to current practice based on best available evidence.
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Explore and implement innovative practice changes.
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Establish functional patterns of communication between councils, committees, task forces, and groups.
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Evaluate outcomes relative to clinical practice.
Quality and safety organizational council
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Identify actual and potential safety issues in the care environment.
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Improve organizational performance using continuous quality improvement science.
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Evaluate trends against internal and external benchmarks and national standards to evaluate practice.
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Establish functional patterns of communication between councils and committees, task forces, and groups.
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Evaluate outcomes relative to quality and safety.
Professional excellence/recruitment & retention organizational council
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Engage in the implementation of evidence-based strategies to attract and retain talented nurses who demonstrate the ideals of the Arkansas Children's Hospital Model of Care and the Professional Practice Model, while promoting a healthy work environment in which nurses can thrive.
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Promote professional nursing practice and nursing excellence, while supporting the advancement of nursing within Arkansas Children's Hospital and the community.
Director council
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Provide a forum for directors to discuss evidence-based practices and policy, relative to leadership and management in support of patient care.
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Facilitate communication and consistency between directors to support the integration of Director Council decisions into actual practice.
Advanced practice provider council
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Provide a forum for all advanced practice providers practicing at Arkansas Children's Hospital to engage in discussions and decisions in relation to the advanced practice provider role.
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Facilitate communication among advanced practice providers to support the integration of the Advanced Practice Provider Council decisions into the practice setting.
Educator council
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Provide direction and guidance for clinical education by promoting collaboration of educators, facilitating interdisciplinary communication and evaluating clinical outcomes relative to clinical education initiatives.
Research council
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Increase the scientific foundation of nursing practice and as the organizing body for all nursing research being conducted at Arkansas Children's Hospital.
Patient care services leadership cabinet
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Provide a forum for open exchange of information between those who are serving in leadership roles to strategize on the advancement of nursing strategies and to discuss key issues and matters of significant importance to nursing within Arkansas Children's Hospital.
Formal evaluations and informal council member feedback over time have resulted in modifications in the shared governance structure and bylaws to enhance effectiveness. In order to evaluate whether councils were optimally functioning, executive leadership made a decision to administer the validated CHS to all members of clinical area–based and organizational councils at the end of the 2020 council year.
Methods
The primary purpose of this quality improvement project was to assess council health within the shared governance environment at Arkansas Children's Hospital. The project was reviewed by the institutional review board (IRB) of the University of Arkansas for Medical Sciences. The IRB determined that the project did not meet the definition of human subject research (IRB # 261653).
The CHS, developed by Dr. Hess and the advisory board members from the Forum for Shared Governance, was used to assess ongoing council health and opportunities to optimize council effectiveness, and ultimately, the shared governance environment at the organization.
The CHS is a 25-item instrument comprising 3 subscales: structure, which includes 3 items assessing key elements of the foundational charter/bylaws; activities, which includes 17 items that measure the processes of council work, such as leadership engagement and decision-making; and membership, which includes 5 items that consider the preparation and support for council members. Percent agreement for each item is scored on a scale of 1 to 5, with 1 representing strongly disagree and 5 representing strongly agree. No total score is assigned for the CHS. The Cronbach's alpha reliability estimate for the total scale was 0.95, with subscale estimates ranging from 0.89 to 0.95. Test–retest reliability estimate for the total scale was 0.754.
Frequency and percentages were used to summarize participant responses on the CHS.
In addition, demographic and professional characteristics of participants were collected and summarized as mean and standard deviation for continuous variables or frequency and percentage for categorical variables. An open-ended question was added to collect narrative data about perceptions regarding council functions or experiences with the shared governance environment at the organization. Participant responses were independently coded and organized into thematic categories.
An e-mail invitation with a hyperlink to access the web-based survey was sent to all members of nursing organizational and clinical area-based councils on the Little Rock campus between October 5 and October 20, 2020.
Results
Seventy-two council members accessed and completed the survey, yielding a survey response rate of 22.9% (72/315). The low response rate is hypothesized to be the result of fewer staff members accessing their e-mails due to staffing demands during the COVID-19 pandemic. Fifty-one percent of respondents served on an organizational council, and 69% served on a clinical area–based council during the previous 12 months. Several respondents that served on a clinical area–based council also served on an organizational council. The majority of council members were registered nurses (50%) and held a bachelor’s degree (56%). Other respondents included advanced practice registered nurses, nurse leaders, educators, and allied health professionals. The average duration of employment as a nurse at the organization was 12 years (Table 2). Ninety-two percent of respondents rated their overall satisfaction with their professional practice as high or very high.
Table 2Demographic and Professional Characteristics of Respondents
Level of council membership, past 12 months (n = 99)
Organizational council
36 (51.4)
Clinical area–based council
48 (68.6)
Coordinating council
15 (21.4)
Age, years (n = 70)
18-24
5 (7.1)
25-34
26 (37.1)
35-44
19 (27.1)
≥45
20 (28.6)
Gender (n = 72)
Female
64 (88.9)
Male
6 (8.3)
Prefer not to say
2 (2.8)
Employment status (n = 70)
Full-time
67 (95.7)
Part-time
3 (4.3)
Highest degree (n = 70)
Diploma/associate
8 (11.4)
Bachelor's
39 (55.7)
Master's/doctoral
18 (25.7)
Other
5 (7.1)
Specialty certification (n = 71)
Yes
51 (71.8)
No
20 (28.2)
Primary professional position (n = 70)
RN
35 (50.0)
APRN
9 (12.9)
Manager/director
9 (12.9)
Educator
7 (10.0)
Other
10 (14.3)
Years practicing as a nurse (n = 66)
13.3 ± 10.4 [Range: 1 to 44]
Years practicing as a nurse atArkansas Children's Hospital(n = 66)
11.6 ± 9.6 [Range: 1 to 44]
Data are presented as n (%) or mean ± SD. Survey responses vary from n = 66 to 72.
Greater than 90% of respondents agreed/strongly agreed that their council has bylaws that define its work, membership, and expectations of council members. Respondents agreed/strongly agreed that the leadership team (78%) and council members (75%) are engaged in council work and meetings. Eighty-five percent to 89% of respondents agreed that the decisions made by council members align with the organization’s strategic goals, are evidenced-based, and reflect the values and preferences of those they represent. Ninety percent of respondents agreed/strongly agreed that council members participate in activities that improve the professional practice environment and the care of patients, the intended goals of the organization’s shared governance model. The greatest opportunity for improvement in council health resided in the membership subscale items. Twenty-four percent of respondents disagreed/strongly disagreed and an additional 28% were undecided that there are strategies to ensure council members have dedicated time to complete council work. Only 38% of respondents agreed/strongly agreed that their council has a process to assess each other’s participation in the council (Table 3).
Narrative commentary to the open-ended question yielded four themes: COVID-19: a new normal for councils; engagement; influence on decision-making; and strengthening councils (Table 4).
Table 4Themes and Participants’ Corresponding Responses Regarding Council Experiences
Themes
Participant Responses
COVID-19: a new normal for councils
“Frontline staff and council leaders are struggling to balance the demands put forth by the pandemic, on a personal and professional level; these things are intertwined and cannot be separated…. Frontline staff and council members are being asked to carry on as normal, but things simply are not normal.”
Engagement
“I think that a designed way to ensure that members are held accountable for attending meetings and performing some work for the council would be amazing. Maybe there is a way to give a ‘grade’ or some way to track performance besides just being a member.”
Influence on decision-making
“They make great plans, [but] then by the time it goes through all of the red tape, nothing changes. There are changes that need to be made at the unit level. Not every unit will fit [within] the same policy.”
Strengthening councils
“We need to look at council chair/co-chair succession planning and try to design a way to successfully train and prepare people for these positions so that they would want to stay in that position for a while.”
In response to the COVID-19 public health emergency, health care organizations are faced with rapidly changing the way that shared governance is sustained within their institutions.
Keeping nurses engaged in nursing professional governance during the COVID-19 pandemic: nursing professional governance structure at Yale New Haven Hospital.
Health care organizations with well-established shared governance models are best able to rapidly shift and respond to staffing and patient care needs in times of crisis.
Shared governance is enhanced through a coordinated council infrastructure of interprofessional team members who have a long history of collaborating and have streamlined communication processes for distribution of important information to key stakeholders. Shared vision also allows the organization to promptly adjust to meet emerging staffing and patient care needs and implement new workflow processes while ensuring safe and quality patient care.
The Arkansas Children's Hospital Coordinating Council, which includes all council chairs and serves as the organizational oversight council for the structure, bylaws, and processes of the councils, performed a SWOT analysis to organize the study findings and assess the organization’s strengths, weaknesses, opportunities, and threats regarding council health (Figure 2). The purpose of this assessment was to guide a strategic plan aimed at optimizing the ways that councils work in order to advance shared decision-making and shared leadership within the organization. In addition, the SWOT analysis identified opportunities to keep nurses engaged in shared governance during the COVID-19 pandemic.
Figure 2SWOT Analysis of Council Health at Arkansas Children's Hospital
An identified strength was the long history of shared governance that is deeply rooted in the mission and vision of the organization. Strong council bylaws, regularly reviewed and updated in response to member feedback, provide detailed guidance on routine council operations. Council submissions require evidence to support a proposed practice change. Interprofessional membership engagement and executive leader presence are seen as positive influences that also contribute to the strength of the council structure. For example, the diverse membership of the research council includes a clinical nurse chair, biostatistician, respiratory and rehabilitation representatives, chaplain, and a parent/family advisor. The membership also includes representation and collaboration of individuals in multiple settings from across the organization. Nurse leader participation in council activities provides opportunities for mentoring and succession planning of current and future council leaders, for facilitating innovations, and for driving evidence and quality in nursing practice.
Weaknesses of the Council
The survey findings identified areas by which the organization might minimize perceived weaknesses in council health. One of the most apparent weaknesses was the need to prioritize staffing to enhance surge capacity during the COVID-19 pandemic. A delicate balance exists in order to maintain a healthy council structure that promotes a culture of staff engagement and empowerment while addressing critical staffing needs during a public health emergency. During the height of the pandemic, councils were encouraged to evaluate meeting agendas and cancel meetings that lacked critical agenda items for member discussion and action. Alternate meeting methods that included video and e-mail meetings were implemented to allow for staff input without the pressure of in-person meeting attendance. Offering an e-mail meeting option also allowed busy as well as off-shift staff to participate at a time more suitable to their work schedule. Virtual meetings permitted clinical nurse participation without the need for travel or to make childcare arrangements.
The realities of staffing during a pandemic often limits the organization's ability to provide protected time for staff to attend council meetings and complete council initiatives. A coordinated effort by councils to prioritize top initiatives alleviated staff pressure to complete multiple clinical area council projects. By focusing on a few organizational initiatives, staff had a sense of contribution while sharing the workload across multiple councils. For example, a standardized handoff process was identified as a priority need by several councils. The research council conducted an evidence-based literature search that led to the selection of the nursing bedside handoff tool. The educator council focused on developing and implementing staff education for using the tool. Clinical area–based councils provided feedback on the identified barriers and facilitators to tool usage. The directors council assisted with the implementation and auditing of the handoff process. The collaboration across councils allowed for a successful outcome to what may have otherwise seemed like a daunting task for a single council.
Organization councils and clinical area–based councils often struggle with insufficient administrative support to distribute communications and council updates as well as to record council minutes. By standardizing meeting minute templates and having each council member submit a written report for agenda items, the accountability and workload was shared across the council, which in turn, promoted more timely communications with other councils. The formation of a central repository for council minutes that is easily accessible to all staff and council members and that is maintained by a central administrative assistant is another avenue to optimize communication with staff and other councils.
Opportunities for the Council
The COVID-19 pandemic provided the organization with several opportunities to improve council health. As staffing concerns increased during the pandemic, councils were given permission to conduct e-mail meetings and suspend nonurgent council activities. The pandemic increased awareness of the need for varied meeting methods as well as a strategic plan to effectively support decision-making during times of emergencies. As the impact of the COVID-19 pandemic began to limit in-person meetings, council meetings pivoted to virtual technology platforms. While leaders and clinical staff struggled on best practices for conducting virtual meetings, council members quickly learned that virtual technology enhances communication and engagement of clinical nurses across settings and shifts.
Keeping nurses engaged in nursing professional governance during the COVID-19 pandemic: nursing professional governance structure at Yale New Haven Hospital.
Councils pivoted their agendas to discuss critical pandemic staffing and patient care concerns as well as innovative solutions to promote staff resiliency during this difficult public health emergency. The coordinating council served as the central command post and focused on how to engage busy clinical nurses in decision-making and ways to best disseminate key information. The organizational council steering committee developed a process for frontline staff to propose clinical nursing practice changes that were then reviewed by the committee and routed to the most appropriate council as well as key stakeholders throughout the organization for feedback and approval. To ensure critical access and communications between staff and leaders, nursing leaders increased unit walk-a-rounds to better identify and respond to rapidly emerging staff and patient care issues, such as availability of personal protective equipment and staffing concerns during the COVID-19 pandemic.
Although the organization had a strong plan for education of council leaders, the survey identified a need for additional member education as well as strategies to hold council members accountable for attendance and active participation. In response to the survey findings, the professional excellence/recruitment and retention council members prepared a welcome letter and recruitment brochure to be distributed to all nurses during the annual council recruitment period. A direct link to the online 2021 new member council orientation in the organization’s learning management system was embedded in an e-mail to all nurses. This updated council orientation included video testimonials by council leaders and members. These recruitment and onboarding materials better facilitated clinical nurses’ transition into their new roles as council members.
To address succession planning of council leaders, the coordinating council explored the “terms of officers” as defined in the bylaws. The term of office for council leaders was based on the need to ensure sufficient duration to promote continuity of council operations while incorporating term limitations that allow clinical staff with leadership ambitions to have the opportunity to gain skills and experiences necessary to be an effective leader as well as to advance their career.
The organization continues to improve workflow processes and to ensure timely communication among councils and clinical staff. Annual council posters that traditionally reported council outcomes during pediatric nurses week pivoted to focus more on reporting pandemic related success stories. For instance, the ambulatory council shared their success with a daily drive-thru COVID-19 testing station for preoperative and symptomatic children. Ongoing dialogue and creativity are needed to support staff engagement and provide innovative solutions to rapidly emerging health care challenges associated with the COVID-19 pandemic.
Threats to Council Health
The COVID-19 pandemic was the most recognized threat to council health. Without strong council infrastructure and processes, times of public health emergencies may paralyze shared decision-making within an organization.
Although the pandemic certainly created numerous workforce and financial challenges, our organization was able to navigate the pandemic by intentionally adapting to change and maintaining an unwavering commitment to shared decision-making and to the healthcare team.
During the pandemic, remote council meetings became the new normal. Although in-person meetings have traditionally been thought to be preferable, the pandemic has provided a unique opportunity to implement and examine the impact of “virtual” shared decision-making on the efficiency of council operations and the shared governance environment within the organization. Council leaders soon discovered that where shared decision-making occurs is far less important than ensuring the process itself occurs. The offering of virtual or hybrid meetings may be superior for some, because it may allow the voices of more clinical nurses across settings and shifts to be heard, a fundamental component of shared governance.
The multiple stressors of the pandemic have led to compassion fatigue, burnout, and turnover among frontline clinical nurses. Despite financial challenges, Arkansas Children's Hospital was committed to retaining staff and continuing to invest in their physical, mental, and social well-being. The coordinating council and the professional excellence/recruitment and retention council collaborated to focus on retention and resiliency initiatives for the nursing staff. Staff were encouraged to focus on self-care and to balance the various demands of all aspects of life brought on by the pandemic in order to promote well-being and minimize illness. Canine-assisted interventions for staff were used extensively for stress reduction. Monthly virtual happy hours used technology and laughter to create social connectedness and foster staff resiliency. Each virtual happy hour ended with a time of personal reflection led by a hospital social worker who fostered an opportunity for nurses to express gratitude, share pandemic victories, and receive words of hope and encouragement. These resiliency efforts have resulted in nurses feeling more happy, hopeful, and connected, and less anxious and lonely.
Conclusions
The CHS was instrumental in Arkansas Children's Hospital assessment of council health. The SWOT analysis aided the assessment of the internal and external environment to determine key opportunities to optimize council effectiveness, and ultimately, the shared governance environment within our pediatric health care organization. An unwavering commitment to the vision of shared decision-making will allow health care organizations to achieve exemplary patient, organizational, and professional outcomes, even when faced with unforeseen challenges, such as a pandemic. Organizations must remain flexible and innovative to maintain an environment supportive of nurse empowerment and shared governance during times of crisis.
Keeping nurses engaged in nursing professional governance during the COVID-19 pandemic: nursing professional governance structure at Yale New Haven Hospital.
Marlene Walden, PhD, APRN, NNP-BC, CCNS, FAAN, is Nurse Scientist Manager at Arkansas Children’s Hospital in Little Rock Arkansas. She can be reached at [email protected] Lee Anne Eddy, DNP, RN, NEA-BC, is Senior Vice President and Chief Nursing Officer, Amy Huett, PhD, RN, NPD-BC, is Director of Nursing Excellence, Austin Lovenstein, MBA, MA, BS, is Research Coordinator, Amy Ramick, DNP, RN, ACNS-BC, NPD-BC, is Nursing Research Specialist, Debra Jeffs, PhD, RN, NPD-BC, FAAN, is Academic Nursing Education Manager, and Angela Scott-Roberson, MNSc, RN, APRN, PCNS-BC, FCNSI, is Director of Acute Care Services at Arkansas Children’s Hospital.
Article info
Publication history
Published online: December 09, 2021
Accepted:
December 6,
2021
Received:
November 16,
2021
Footnotes
Note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose. This project did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors would like to thank all the members of the organizational and clinical area-based councils at Arkansas Children's Hospital. Your commitment and engagement to shared decision-making allows the organization to deliver exceptional care to our patients and families. The authors would also like to thank Dr. Robert Hess from the Forum for Shared Governance for his thoughtful review and editing of this manuscript.
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