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Unlike other disciplines, control over practice is a recurrent issue in nursing. As long ago as 1988, a national sample of 3,500 nurses identified that being "allowed" to exercise nursing judgment for patient care was one of the most important factors in their practice (Huey & Hartley, 1988). Even today, degree of control over practice persists as an important research area in Magnet hospitals (Kramer & Schmalenberg, 2003).
Definition and History: Who’s the Boss?
But why would this be an issue? Because education, professional standards, and judgment are not the only determinants of the practice of nurses who work in traditional health care institutions. As employees, nurses must structure their practice within rules imposed by their employers, often in the form of policies and procedures that have a profound effect on how nurses deliver patient care. The scope and amount of resources made available by the employing organization further influences their practice. Fortunately, administrators and managers who are also nurses help create these policies and budgets within most health care organizations. However, the nurses who actually deliver care are often absent from policy-making processes and structures. Nursing shared governance emerged as one way to give these clinical nurses equal footing with managers to allow them to participate in the decision-making processes that affect their practice.
...the nurses who actually deliver care are often absent from policy-making processes and structures.
Governance is about power, control, authority, and influence. It answers the question in an organization, "Who rules?" Nursing shared governance extends that rule to nurses. It surfaced as a radical break from traditional hospital governance where nurses had little power within a rigid formal hierarchical bureaucracy. Nursing shared governance is a managerial innovation that legitimizes nurses’ control over practice, while extending their influence into administrative areas previously controlled only by managers (Hess, 1998b).
Nursing shared governance has a distinguished pedigree. Christman (1976) first introduced the yet-unnamed concept in his description of the autonomous nursing organization, which would give nurses an equal voice with physicians within hospitals. Shortly thereafter, the label of shared governance first appeared in nursing literature in Cleland’s (1978) adaptation of a university model of faculty governance. Cleland proposed a model that reconciled the interests of different organizational groups through the distribution of power to formulate policy.
The 1980s were a heady time for humanizing models, such as participative management and decentralization, which involved people in the organizations. In health care as well as academic environments, shared governance traversed the country, adapting along the way. An evanescent concept, it generated unique structures and processes wherever it was implemented. As an innovation, it arose differently from organization to organization. As administrators adopted the models of early innovators, they changed those programs and adapted them to their own organizational environments. As others later adapted those models, permutations became endless.
Documented early implementation sites in major hospitals included St. Joseph's Hospital in Atlanta, GA (McDonagh, Rhodes, Sharkey, & Goodroe, 1989; On the Scene, 1982); St. Michael's Hospital in Milwaukee, WI (Pinkerton, Eckes, Marcouiller, McNicols, Krejci, & Malin, 1989; Pinkerton & Schroeder, 1988), Carondelet St. Mary's Hospital in Tucson, AZ (Ethridge, 1991; Ethridge & Lamb, 1989); and Rose Medical Center in Denver (Johnson, 1987). The thinking that fueled some of these initial experiences is eloquently reflected in such books as Porter-O’Grady and Finnegan’s (1984) Shared Governance for Nursing: A Creative Approach to Professional Accountability and McDonagh’s (1990) Nursing Shared Governance: Restructuring for the Future. One of the most precisely articulated visions of shared governance can be found in a letter to the editor of the Journal of Nursing Administration, "Researching Shared Governance – A Futility of Focus," [PDF file] submitted by Porter-O’Grady (2003).
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