“If you want to build a ship, don’t drum up the men to gather wood, divide the work and give orders. Instead, teach them to yearn for the vast and endless sea.”
-Antoine de Saint-Exupery

This year marks the 30th anniversary of the creation of Rush University Medical Center’s Professional Nursing Staff (PNS),
one of the nation’s first nursing shared governance organizations. This article describes the philosophical underpinnings of the shared governance model developed at Rush and provides practical suggestions on how your organization can form and sustain a lasting culture of strong nursing shared governance.

The authors of this article have served as elected PNS presidents. As a group, our experience in this role spans more than 30 years of Rush history. In 2012, Rush Oak Park, our affiliated 120-bed community hospital, created the Rush Oak Park Nursing Shared Governance Organization (NSGO). This effort was led in part by author Rachel Start, Magnet Program Director and former president of the Rush PNS.

Foundation first

As any architect or engineer will tell you, one of the prime aspects of building construction is selecting a solid foundation. Structures that aren’t built on a strong foundation commonly need extensive remodeling or support. For example, the famous Leaning Tower of Pisa in Italy began its iconic tilt in 1178 due to an unstable foundation of soft soil on one side. It continued to tilt over the centuries and required a decade-long, $30-million stabilization and restoration effort, completed in 2001. Similarly, when creating shared governance in a nursing organization, you must start with a solid foundation of nursing professionalism, philosophical underpinnings, and a vision for the future.

Professional accountability

As a profession, nursing is accountable for providing safe, high-quality, patient-centered care. This accountability to the patient is at the heart of our professional work, serving as the foundation of a pursuit for strong, lasting shared governance. Shared governance supports nursing in the self-regulation of practice and provides structure for excellence in patient care.

Engage all nurses

A strong shared governance model can revolutionize nursing in an organization. If you’re in the process of creating shared governance, make sure to involve nursing staff from all levels and areas during the initial planning stage. Take the time to gain a good understanding of what nursing shared governance could mean to your organization.

At Rush in the early 1980s, our discussions revolved around the concept of shared governance and its potential implications for nursing practice. We focused on building support from nurses throughout the organization and even took a formal vote of all nurses to determine if they supported the concept. As you move toward designing or revising your shared governance model, make an effort to involve all key stakeholders starting from the early steps of the process to promote successful adaptation to this major organizational change.

At Rush Oak Park this past year, shared governance leaders participated in retreats and town halls to educate and engage the nursing staff about shared governance. Engaging all nurses helps create a lasting culture of nursing professionalism through shared governance.

The importance of parity

The journey toward shared governance at Rush started in the late 1970s with the vision of an autonomous nursing staff presented by Dr. Luther Christman, Vice President for Nursing Services and dean of the College of Nursing. His belief that nursing is a full professional partner with medicine and hospital administration in delivering care inspired us to develop a structure that placed nursing in a parallel position of responsibility and accountability with the medical staff.

As we created our shared governance structure, we intentionally paralleled the medical staff organization. This parallel structure has provided a shared understanding of the two disciplines in our organization. We have parallel officer positions, parallel titles, and parallel committees. Both groups report and are accountable to the Rush board of trustees. Creating a parallel structure allows the organization to engage nursing as an equal stakeholder in patient-care delivery and the pursuit of organizational goals. (See Parity in action by clicking the PDF icon above.)

Strong bylaws: Crucial to shared governance

Bylaws are a vital step in creating and maintaining shared governance. At Rush, the PNS began when the nursing staff voted on adoption of bylaws. We didn’t immediately jump into forming committees or meetings, but instead intentionally laid out the rules and governance of the nursing staff through bylaw creation.

Bylaws are the most important document in any shared governance organization. They define the primary characteristics of the organization, how it should function, and what rules govern the members and leadership. Bylaws also delineate rules or processes that are so important they may not be changed without prior notice to members and a formal vote and agreement by a majority of members.

Bylaws typically include:

• mission statement
• eligibility for membership
• officers and executive board
• meetings
• election process
• committees and subcommittees
• amendment procedures for changing the bylaws.

Bylaws shouldn’t be so prescriptive that they’re rigid, or so vague that they’re cryptic. But exceptions exist. Functional processes, such as election of officers, should be specific and clear to eliminate possible alternate interpretations. In other areas, such as task forces and committees, bylaws can be general and allow flexibility and change over time.

Bylaws should outline the key elements inherent in your shared governance organization. Consider including such topics as practice privileges, corrective action, election of members, term limits for chairs or officers, peer review, or other topics unique to your organization. The Rush PNS bylaws are a legal document approved by the board of trustees. We revise and update them every 4 years.

A strong foundation: The key to sustainability

Shared governance is both a philosophy and a structure for professional accountability that helps an organization achieve high-quality, patient-centered care. A shared governance model can’t be imported from another system or created overnight. Rather than focusing on a system of committees, those developing the shared governance model should focus on creating a foundational culture of strong nursing professional accountability, interprofessional parity, and engagement of nurses at all levels and in all areas. Otherwise, they risk building a structure of form with no substance—one that might tilt or sink over time.

As nursing shared governance becomes hardwired and sustained, an autonomous, energetic, and engaged staff emerges to bring nursing-specific knowledge to the interprofessional decision-making table, helping to ensure that nurses remain key partners in the pursuit of high-quality care.

Rachel Start is Magnet Program Director at Rush Oak Park Hospital in Oak Park, Illinois. Benson Wright is Magnet Program Coordinator at Rush University Medical Center in Chicago. Marcia Murphy and Cathy Catrambone are associate professors at Rush University College of Nursing in Chicago. Erik McIntosh is a nurse practitioner in the Department of Internal Medicine at Rush University Medical Center.

References

Christman L. The autonomous nursing staff in the hospital. Nurs Admin Q. 1976;1(1):37-44.

Shrady N. Tilt: A Skewed History of the Tower of Pisa. New York, NY: Simon & Schuster; 2003.