The governing bylaws as well as policies and procedures pro- vide the framework within which the individual sections of the organization operate. Whether these sections are organized according to service lines, product lines, or departments such as nursing or radiology, their nurse leaders are involved with, and often directly responsible for the development of and com- pliance with policies, standards of practice, and organizational bylaws that influence the overall organization.
In 1981, Tim Porter-O’Grady, PhD, developed a concept of shared decision making referred to as “shared governance.”8 Shared governance is defined as a systematic means of provid- ing a communication forum for nursing that effects individual input into the professional practice of nursing. Current gover- nance models make use of this concept to varying degrees, depending on the organization and the cultural readiness of the organization to uphold the model.
A key element of shared governance is the presence of nursing- driven councils that have primary responsibilities for such things as education, practice, leadership, research, quality, and advanced practice. The Magnet Recognition Program®recognizes that organi- zations that achieve such recognition are generally flat (non- hierarchical), flexible, and decentralized. In these high-performing organizations, nurses throughout the organization are involved in self-governance and in decision-making processes that establish standards of practice and address issues of concern. The flow of information becomes bidirectional in that it flows “in and out as well as among” staff, leadership, and others who contribute to the patient care processes. Shared leadership approaches take various forms, which mature and evolve over time. The philosophy and its embracement by leadership and staff become the underpinnings of the success of this governance model.
Most often, the shared leadership “groups” that are formed are referred to as “councils.” The councils meet on a regular basis and then the chairs of these councils also meet in a sort of “cab- inet meeting” to share their activities and work on cross-council
(bidirectional function) activities. The cabinet allows the practice council to know what the education council is doing, as well as what the leadership council is engaged in, and vice versa.
Shared governance is one means by which to become involved in health care policy at the individual and organiza- tional level. Many staff nurses who aspire to leadership positions may see council involvement as a first step on that journey. Staff is encouraged to participate in the shared governance system so that the empowerment message is heard throughout the organi- zation. For example, an organization might have an interest in the role and reimbursement of the advanced practice nurse. The advanced practice council could then study the regulatory infor- mation and provide feedback to both the nursing division and the organization overall. This one action could have profound effects on a singular discipline within the organization. This example also highlights how nurses and their colleagues can par- ticipate in the process by which an organization’s policy evolves.
Such cross-organizational involvement allows nursing leader- ship to incorporate many perspectives in the positions and activi- ties for which they advocate organization-wide. Various models exist to depict communication and collaboration between and among professional colleagues. A popular shared leadership model is depicted in a circular fashion (Fig. 4–1). A legislative/hierarchi- cal model is also widely used and functional (Fig. 4–2).
We often hear the phrases “grassroots effort,” “your vote counts,” and “as an individual, you can make a difference” in the context of political campaigns. Whether at the bedside or sitting in a professional organization meeting, nurses have the opportunity (and responsibility) to work on policy issues. Keep in mind that every pol- icy has some influence—direct or indirect—on patient care.
Therefore, nurses should be aware of medical staff bylaws and poli- cies as well as the rest of the organization’s policies. Nurses and nurse leaders, especially should be sensitive to those times when staff may be tempted to do a “work around” rather than comply with a particular policy. The term “work around” depicts a shortcut per- formed in response to various factors, such as complexity of the designed process or the fact that the designed process takes longer than the provider desires. Enough literature exists to acknowledge
Research council
Advance practice council
Leadership council
Clinical practice council Education
council Quality
council
Nursing cabinet
Figure 4–1 Typical shared governance model.
Nursing cabinet
Nursing leadership
council
Nursing research council
Nursing education
council
Nursing advanced
practice council
Nursing practice council
Nursing quality council
Figure 4–2 Legislative/hierarchical model.
that work arounds can lead to errors and greater patient safety risks, as well as additional steps in the work process. When these work arounds are known, it behooves everyone in the organization to examine the policy, identify the respective problems that encour- age the shortcut, and develop a mutually beneficial solution.
At all times, the voice of the nurse is the voice that helps improve patient care. Organizations often recognize the chief executive officer (CEO) as the spokesperson for the organiza- tion. Remember, though, that nurses have a perspective that the CEO and other leaders do not have. It is vital that everyone rec- ognize the value of his or her own role and become involved in improving these complex systems. When an organization offers opportunities to learn more, get involved. Identify the policy mak- ers, whether they work with your hospital, or with regional, state, or federal leaders. Your role in advocacy is a means to ensure needs for today as well as for tomorrow. As an advocate for your patients and a provider of care, your voice is an important piece of the policy puzzle and may go far to influence the development of organizational, state, and federal legislation and policy.
“Rural health care will be drastically changed because of the demographics within these populations. Many of the communities in rural states that have a hospital or nursing home will not have a population large enough to support one or both of the facilities. Residents will be required to travel farther for care. Providers will not be able to provide
‘outreach’ care due to inefficiencies and windshield time. The number of professional staff will also have an impact on the ability to provide care. Technology will need to provide a significant role for future rural health care delivery.”
—Terry Watne, MS, RN; Administrative Director, Altru Health System, Grand Forks, North Dakota
CASE STUDY
One in nine people has chronic kidney disease.9The number of people diagnosed with chronic kidney disease rose 30% in the past decade, and it now accounts for 24% of Medicare’s overall spending.9Furthermore, the incidence of kidney dis- ease continues to rise sharply, increasing 3.4% between 2005 and 2006, alone. Medicare provides funding for chronic kid- ney disease through its end stage renal disease (ESRD) pro- gram. In 2008, ESRD patients accounted for 1% of Medicare beneficiaries and 7% of total Medicare spending. Total spend- ing for ESRD (Medicare and other payers included) is now
$33.6 billion per year. One might wonder how this example relates to policy.
Karen has been passionate about the renal population since she began working as a staff nurse in the dialysis unit in 1976.
Since that time, Karen has taken it upon herself to become familiar with the rules of, and participate in, the renal network that oversees care for patients with ESRD in defined areas of the United States. The renal network was established by Medicare to monitor policy, evaluate patient outcomes, and assist providers in providing the best care to this fragile patient population.
The renal network and other professional organizations for renal nurses and administrators have developed “talking points” that can be used at the local level to influence health care policy. These talking points were developed as part of a national strategy to educate the public, as well as state and fed- eral representatives.
Most recently, the greatest issue affecting the renal population has been the risk of death from cardiovascular disease in con- junction with chronic kidney disease. The National Institutes of Health noted the importance of detecting and treating cardiovas- cular risk factors in patients with kidney disease.10Karen took it upon herself to become involved professionally as the advocacy representative for her state. Initially she met with her supervisor at her place of employment to ensure that the work she was doing was supported by her employer. Karen then met with her
Assessment Questions
1. What is the most burning issue for you as a nurse in provid- ing care for your patients?
2. If you could help change the impact you have on patient’s lives, what change would you make?
3. How would you go about influencing this change?
4. Are you a member of your professional organization? Have you used this avenue to address your burning issue?
5. What issues locally and nationally are being discussed and how do these issues relate to your burning issue?
6. What can you do to see that your burning issue is recognized and addressed by those in charge of health care policy?
state senators, as well as the state’s congressional representatives to discuss this growing and very expensive health care issue.
When the state and federal legislators held town hall-style meetings in her state, Karen was there with her folder and the talking points that were imperative to the financial and clinical success of this national program. It was through such grassroots efforts by many individuals that increased attention is now being paid to cardiovascular risk in chronic kidney disease patients.
REFERENCES
1. Pear, R. (2008, December 19). Budget Office Sees Hurdles in Financing Health Plans. The New York Times.Retrieved from http://www.newyorktimes.com
2. Renner, C. MedAmerica Financial Services newsletter. Available at:
http://www.medamerica.com/mafs/Newsletters/Newsletters.asp 3. Doty, M. M., Rustgi, S. D., Schoen, C., & Collins, S. R. (2009,
January). Maintaining health insurance during a recession: Likely COBRA eligibility. The Commonwealth Fund, Vol. 49. Available at:http://www.commonwealthfund.org/Content/Publications/
Issue-Briefs/2009/Jan/Maintaining-Health-Insurance-During-a- Recession—Likely-COBRA-Eligibility.aspx
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Best Practice
4. Report describes “hidden tax” resulting from public program underpayments. Available at: http://www.milliman.com/expertise/
healthcare/publications/rr/pdfs/hospital-physician-cost-shift- RR12-01-08.pdf
5. Redefining Healthcare, Harvard Business School Publishing, Michael E Porter and Elizabeth Olmstad Teisberg, May 2006.
6. Anderson, G. F., Frogner, B. K., Johns, R. A., & Reinhardt, U. E.
(2006). Health care spending and use of information technol- ogy in OECD countries. The Commonwealth Fund, Vol. 42.
Available at: http://www.commonwealthfund.org/Content/
Publications/In-the-Literature/2006/May/Health-Care- Spending-and-Use-of-Information-Technology-in-OECD- Countries.aspx
7. Baucus, M. (2009). Call to action: Health reform 2009, p. 17.
Available at: http://finance.senate.gov/healthreform2009/
finalwhitepaper.pdf
8. Porter-O’Grady, T., & Finnegan, S. (1984). Shared governance for nursing: A creative approach to professional accountability.
Rockville, MD: Aspen Publishers.
9. The Facts About Chronic Kidney Disease. Available at:
http://www.kidney.org/kidneydisease/.Retrieved July 18, 2009.
10. National Institutes of Health press release, October, 8, 2008.
Available at: http://www.nih.gov/news/health/oct2008/niddk- 08.htm. Retrieved July 18, 2009.
T
TE EC CH HN NO OL LO OG GY Y
“Technology will become the most profound next step in health care reform. The ability to utilize technology for patient care management will serve to enhance the quality, safety, and efficiency in our health care system.”
—Donna Herrin, MSN, RN, NEA-BC, FACHE;
Clinical Associate Professor, University of Alabama, Huntsville, Alabama;
Senior Advisor, Methodist Healthcare, Memphis, Tennesse;
2009 President, AONE Board of Directors