Embracing a Nursing Shared Decision Making Model

Embracing a Nursing
Shared Decision
Making Model
The Department of Nursing in Mayo Health System’s western region is
journeying from a traditional management model to a Shared Decision
Making Model. Shared decision making is the foundation that supports
our vision of being a premier nursing organization, building upon a
culture that is patient centered, caring and engaged in nursing inquiry.
This booklet details our Shared Decision Making Model and how we
are making our vision a reality.
What is a Shared Decision Making Model?
A Shared Decision Making Model is a collaborative governance
structure that gives professionals a voice regarding issues that affect
their practice. It is also known as Shared Governance. In Mayo Health
System’s western region, we are incorporating the principles of
shared decision making into our nursing administrative model. These
principles include:
• Staff nurses must have an active role in making decisions, forming
policies and/or controlling actions and behaviors (Anderson, 1990).
• Sharing power promotes interdependence and cooperation (Shidler,
Pencak & McFolling, 1989).
• Professional workers deserve an accountability-based governance
system (Porter-O’Grady, 1987).
• The environment must promote autonomous staff nurse practice
(Pinkerton, 1988).
What does shared decision making look like?
Shared decision making encourages and expects participation by
nurses at all levels of the organization. It promotes working conditions
wherein individuals work to their fullest potential.
When shared decision making is present:
• Management moves from directing and controlling to coaching,
guiding, questioning and facilitating.
• Centralized or decentralized responsibility is replaced with mutual
shouldering of responsibility.
• Tight, hierarchical reporting relationships give way to a loose
interactive structure.
• Respect, cooperation and collegiality replace competition and
conflict.
• Communication becomes multidirectional, open and free-flowing
instead of only up or down.
• Purpose is shared, understood, and
accepted by all.
• Problems are discussed and
eliminated — frustration and
“burnout” are replaced by challenge,
enthusiasm, and progress.
• Commitment is instilled in members: commitment to each other and
to the quality of work that results from their efforts.
(Taken from: Neis, M.E. and Kingdon, R.T. (1990). Leadership
in Transition: A Practical Guide to Shared Governance. (1st Ed.).
Schaumberg, IL: Nova I, Ltd.)
How does shared decision making differ from a
traditional hierarchy?
Nursing leaders and staff nurses function differently under a Shared
Decision Making Model. This table contrasts expectations for each
group under both models.
Traditional Hierarchy
• Follow Directions.
Staff
Expectations • Abide by the rules.
• Follow the chain of
command.
• Do the job, don’t complain.
• Don’t make a mistake.
• Run a tight ship.
Leader
Expectations • Keep the boss informed.
•
•
•
•
•
•
•
Shared Decision Making
• Ask the questions, make a
suggestion.
• Days of free complaining
and blame-placing are over.
Participate in active problem
solving.
• Use effective communication.
• Take responsibility for the
environment and for the
quality of products/services.
• Talk to those necessary to get
the job done. Embrace errors.
•
Give up control, be inclusive
Punish mistakes; deny errors.
in style.
Set your own style.
• Encourage questioning, invite
Follow the chain of command.
challenges.
“You’re the boss, you decide.” • Show the way by being an
Keep the troops in line.
example for others to follow.
The boss is always right.
• Find out for yourself!
Don’t rock the boat.
How do nurses benefit from a shared decision making
process?
• Nurses define, delineate, create, approve and evaluate all nursingpractice activities.
• Nurses assume full responsibility and accountability for all activities
related to nursing practice.
• Practice related issues are dealt with by practicing nurses, rather
than by managers.
• Nurses move from subservient to autonomous roles as they exercise
authority over decisions related to their practice.
• Nurses experience more control over their working environment and
the professional practice of nursing.
• Staff nurses emerge as leaders as they assume responsibility for their
practice.
• The power base for nursing practice shifts to the hands of the
practicing nurse, who is the major provider of care in the hospital
setting.
• Nurses’ attitudes towards the work environment improve.
• Nurses experience an improved climate for innovation and change.
• Nurses perceive themselves as more satisfied with their jobs.
• Nursing clinical expertise is recognized and valued in a continually
changing healthcare system.
• Physicians become more aware of the decision-making skills of the
nurses and recognize the positive impact nurses have on patient care
delivery and outcomes.
What types of decisions does shared decision making
allow nurses to make?
Within the Department of Nursing in Mayo Health System’s western
region, there are two domains of decision making: managerial and
professional. Managerial decisions remain the responsibility of
administrative leaders. Professional practice decisions become the
responsibility of staff nurses and allied health care professionals. The
following table lists examples of decisions that lie within each domain:
Management
Professional Practice
• Providing a new program
• Nursing strategic planning
• Disciplinary action and process
• Nursing practice standards
• Policies and procedures
• Continuous improvement
• Personnel issues
• Budget and resources
• Design of strategies and budgetary
processes
•
•
•
•
Peer review
Patient care
Professional development
Priorities for staff development
There are times when both domains are involved in the decision
making process. This diagram illustrates the continuum of decision
making from the managerial domain to the professional practice
domain.
COMMAND
CONSULTATIVE CONSENSUS
HIGH
MANAGEMENT
(Individual)
ce
an
t
ep
c
Ac
e
m
Ti
PROFESSIONAL
PRACTICE
(Group)
LOW
Decisions made solely by management are often command decisions.
Command decisions usually involve very few individuals, take the
least amount of time and often have low acceptance. On the other side
of the continuum is consensus. Consensus involves all individuals and
takes the greatest amount of time, but is also associated with greatest
amount of acceptance. There will always be some command decisions
within any organization, but consensus is the preferred method of
decision making under a Shared Decision Making Model.
How does shared decision making work?
The foundation of the Shared Decision Making Model are the councils,
committees and meetings which allow nurses to engage in making
decisions that affect their practice. Staff nurses comprise 60% or more
of the membership within the councils, committees or meetings. This
diagram illustrates flow of information between the various councils,
committees and meetings in the Shared Decision Making Model for the
Department of Nursing in Mayo Health System’s western region.
Leadership
Council
DivisionMeetings
StaffMeetings
InpatientCharge
NurseCommittee
Data&
Documentation
Committee
Skin
Quality
Committee
Inpatient
Manager
Meeting
Coordinating
Council
&Safety
Council
Falls
Committee
Ambulatory
Manager
Council
Professional
Practice&
Education
Council
Restraints
Committee
Department of Nursing
Shared Decision Making
Diagram for Mayo Health
System’s western region
AmbulatoryCharge
NurseCommittee
Policy&
Procedure
Council
Recruitment
&Retention
Council
Information Flow
Reporting Relationship
Unit
Councils
8.2010
Group Structure
Group Overview
Defined Groups
Councils
Councils are the core
workgroups that comprise
our Shared Decision
Making Model. These
ongoing groups have
diverse representation
and support advancement
of organizational and
departmental goals. Our
model includes seven core
councils:
• Nursing Coordinating
Council
• Nursing Leadership
Council
• Nursing Policy and
Procedure Council
• Nursing Professional
Practice and Education
Council
• Nursing Quality and
Safety Council
• Nursing Recruitment
and Retention Council
• Ambulatory Nurse
Manager Council
• Unit Councils
Group Structure
Group Overview
Defined Groups
Committees
Committees are ongoing
groups sanctioned by
a council. They have a
focused scope of work
with goals that are
measurable and link
directly to the purpose
and objectives of the
sponsoring council.
Committees send
recommendations to
councils for action. Like
councils, committees
support shared decision
making with optimal
participation while
operating efficiently.
• Data & Documentation
Committee
Meetings are organized
by leadership to discuss
information from council
and committees, or other
pertinent topics. Meetings
provide a venue for
clarifying information
and presenting
possible questions or
recommendations that can
be taken back to councils
or committees for further
analysis and discussion.
• Charge Nurse Meeting
Meetings
• Falls Committee
• Restraints Committee
• Skin Committee
• Inpatient Charge Nurse
Committee
• Ambulatory Charge
Nurse Committee
• Director/Patient
Care Manager/
Administrative
Supervisor Meetings
• Division Meetings
• Inpatient Nurse
Manager Meetings
• Staff Meetings
Who can serve on a council or committee?
Nurses in good standing (with no written corrective action in the past
six months) who have had six months experience working in their
area of nursing and are employed at 0.6 FTE or greater, are eligible to
participate on councils and committees. Ideal candidates embrace a
global view of nursing practice issues, and are willing and able to meet
professional responsibilities of the council.
Because each council is comprised of no more than 12 members,
there is a nomination and election process for selection of members.
Members serve for a two year term, and are expected to attend
75 percent of the meetings. Additional responsibilities include
representing their practice area
by engaging and gathering staff
input and communicating council
information back to staff.
For more information on the
Shared Decision Making Model
for the Department of Nursing in
Mayo Health System’s western
region, go to the Nursing website
on ISJWeb or see your Nurse
Manager, Nurse Director or the
Chief Nursing Officer. Together
we can achieve excellence
through shared decision making.
Bibliography
A complete bibliography of references used for developing this
Shared Decision Making Model may be found on our website:
www.isj-mhs.org. From the menus on the left, select Nursing, then
About Us, and finally, Decision Making.
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1025 Marsh Street, P.O. Box 8673
Mankato, MN 56002-8673
507-385-2692, 507-385-5659 or 1-800-327-3721, ext. 2620
www.isj-mhs.org
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