Integrating shared governance with quality improvement to improve RN satisfaction, change practice and improve outcomes

Purpose:
Based on 2009 NDNQI RN Satisfaction Survey, we needed to improve satisfaction with decision-making and professional status. We also needed to improve quality indicators. Our goal: implement a unique model of shared governance that integrated quality improvement, so that nurses own their practice.

Significance:
A gap between knowing best practice and doing it is the capacity of the staff to lead efforts to improve the quality of their own work. To build capacity, we integrated into shared governance best practices from implementation science: structure, evidence, context, process and facilitation.

Strategy and Implementation:
Following the 2009 NDNQI RN Satisfaction Survey, we conducted deep dives on each unit and identified global aims that aligned with our practice model: Care delivery system, professional development, decision-making and professional relationships. [The patient is at the center.] To develop a structure for decision-making, and mindful of why shared governance fails, nursing leadership met and conferred with fledgling Unit Practice Councils (UPCs) to develop an evidence-based shared governance model. As one purpose of UPCs is to “participate in decisions and processes that establish and review standards of practice,” we developed a toolkit adapted from the Clinical Microsystems improvement process and conducted workshops for UPC members in this approach. UPC meetings are very structured; aims are based on internal and external evidence for practice; and PDSA cycles are tested. The UPCs receive real time facilitation at meetings by the nurse researcher, who conducted the workshops.

Evaluation:
One year later, UPCs are embedded in unit culture; their aims consistently align with our practice model; satisfaction with decision-making and professional status improved significantly in NDNQI RN Survey 2010; staff sustained measurable practice changes; and select quality indicators improved.

Implications for Practice:
To improve the quality of care, nurses must own their practice and develop the skills to do so. The work requires a dogged, patient and concerted effort by nursing leadership and UPCs together. Support during UPC meetings from someone with facilitation and improvement skills is critical.