How to Keep Your Nurse Governance System Effective and Dynamic

Continuous care, attention, and making changes when needed are keys to a successful nurse professional governance system, a Vermont CNO says.

Shared governance is pivotal to strengthening professional nursing practice, but it requires more than simply a structure, says Peg Gagne, MSN, RN, chief nursing officer for University of Vermont Medical Center (UVMMC), a 500-bed academic medical center in Burlington, Vermont, with a staff of about 1,800 nurses.

"It needs continuous care, attention, advocacy, and that 'care-and-feeding' piece to make it successful," she says.

Gagne was part of the team that successfully redesigned UVMMC's Nursing Professional Governance (NPG) system.

UVMMC previously had a limited shared governance structure with nonstandardized departmental councils and a global nurse practice council that inconsistently involved clinical nurses in proposals and implementation, according to Gagne.

"The functionality of it had drifted a little bit," she says.

So, in 2017, a redesigned governance structure rolled out, featuring an inclusive approach, rather than the previous leadership-driven, top-down model, and requiring active engagement of clinical nursing staff in shared decision-making, Gagne says.

UVMMC's new structure was designed to offer nurses more autonomy than ever before.

The structure

A flow chart of the service-line structure places point-of-care—the unit practice councils—at the top of the chart, and, in descending order, the seven service line councils, six global councils, and organizational and governance leadership at the base.

Unit practice councils

The unit practice councils, organized by service line, assemble nurses who care for similar patient populations.

The medicine and oncology service line, for example, includes such departments as renal services, radiation oncology O.P., breast care center O.P, infection prevention, and the infusion O.P. clinic in its practice councils.

Service line councils

Seven service line councils were created for the new structure. Over the years they've been slightly tweaked and adjusted, and currently consist of:

• Ortho & surgery
• CV & neuroscience
• Emergency care, access & mental health
• Maternal-child health
• Periop
• Ambulatory care
• Medicine & oncology

Global councils

Four global councils initially were established representing a specific quality focus: safety and quality, patient and family experience, professional development and scholarship, and nursing practice.

But in the "care and feeding" of the structure, global councils were changed, redesigned, and added, and the NPG currently has six global councils: communications, patient family experience; professional development & scholarship, nursing practice, experience & wellness, and LNA (licensed nursing assistant).

Coordinating council

The foundation of the structure is the coordinating council, whose members include the clinical nurse chairs of the global councils, UVMMC's chief nursing officer, and other nurses.

The coordinating council ensures alignment of work across councils so the councils' work matches the organization's strategic priorities, according to Gagne.

Making continual adjustments

The new structure eliminated the unit-based practiced councils, instead opting for a task force model.

"If you as a unit had a problem that you wanted to address and work on, you pulled a group together [to be] very problem-focused, but there wasn't an ongoing unit-based practice council as part of the structure," Gagne says.

As part of the "care and feeding" of the new shared governance structure, the hospital conducts yearly evaluations pinpointing its strengths and weaknesses, so adjustments can be made, and one of the first evaluations resulted in the return of unit-based practice councils.

"We really heard from our staff that they missed that unit-based practice structure," Gagne says. "They really wanted that forum to brainstorm ideas, evaluate the unit-based data, and be a generating group for looking at the care model on the unit and deciding what issues they needed to address."

"So, we built back the unit-based practice councils into the model about two years ago," she says, "but with COVID, it has taken a little while to get them back up and running."

During this same period, they were shifting to a collaborative leadership model on each of the units, where the nurse manager is supported by a medical director, a physician partner, and a quality partner, Gagne says.

"With bringing back the unit-based practice councils, which are more nursing focused, along with this collaborative leadership team on the unit, it really has started to strengthen that frontline staff voice in advancing practice issues," she says.

Programs from the front lines

One of the first projects that came out of the new structure was from the medicine & oncology service line council, which had implemented "The Pause," where, after a patient death, onsite caregivers who served that patient gather, along with the patient's family if they choose, and take a moment to recognize the patient and acknowledge the caregivers, Gagne says.

"The Pause has gone from initially a unit-based practice to throughout the organization," she says.

During a Joint Commission visit, a surveyor happened to visit the intensive care unit (ICU) when a patient had died, and caregivers were conducting a Pause.

"The Joint Commission surveyor said, 'I'm taking this as a best practice on the road with me,'" Gagne says.

Other shared governance initiatives include:

• Creation and implementation of a Nursing Professional Practice Model—multimodal implementation including presentations, flash cards, standing displays, incorporation into document templates, and tips for incorporating into staff/other meetings.
• Creation/piloting a patient-belongings box to reduce lost patient items.
• Bringing and maintaining the Daisy and Bee Award at UVMMC to recognize outstanding nurses and clinical staff.
• Improving hand-offs throughout the perioperative area.
• Developing a quick nurse reference guide called Know Your Resources to address most common resource needs: procedure guide, drug lists, interpreter services, etc.

Achieving satisfactory staffing

A collaborative stance with frontline nurses has helped UVMMC achieve staffing levels acceptable to their nurses—a challenge facing nearly every health system or hospital.

"It's another way that we have been trying to empower and support that frontline staff voice in impacting professional nursing practice by having their direct review and involvement in what staffing model and staffing levels should look like across the organization," Gagne says of the two-year project.

"A unit-based group of staff and leaders reviewed national benchmarks in terms of staffing levels for every unit and department across the organization, including our ambulatory sites as well as our in-patient sites," she says. "They talked about the care delivery model in each area, looked at the benchmarks, compared the work they were doing to where the benchmarks were coming from and then came back with recommendations of what the staffing model and levels should look like in each area."

Those recommendations were evaluated in partnership with their nursing union's bargaining unit, she says.

"The president of the nurses union and I spent countless hours meeting with each of these groups over the fall and spring, getting their recommendations and evaluating the recommendations," she says. "We ended up adding a substantial number of FTEs to our next year's budget to support the recommendations of the unit staffing collaborative."

"It was a big piece of work," she says, "but it was really needed and had a good outcome."