44 November October 2014 2014 • Nursing • Nursing Management Management
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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Shared governance in an Army clinic:
Implementing unit practice councils By Brad Franklin, MSN, RN, FNP-C; Marguerite Murphy, DNP, RN; and Pamela Cook, DNP, RN, NE-BC
S
hared governance and Army medicine are two concepts that wouldn’t generally be considered joined together in the spirit of collaboration. The U.S. Army Medical Department and its numerous facilities, like other federal agencies, has a centralized power hierarchy that’s not conducive to sharing authority. Often, such power is a result of federal laws that prohibit local control over certain functions.1 In the military healthcare setting, officers with higher rank usually have more authority to make decisions. Staffing at many military facilities utilize a large civilian work force.2 For Army facilities, 57% of RNs and 67% of LPNs today are civilian and fall outside the military rank system.3 The strong civilian workforce is critical to ensuring quality care for soldiers and their families. Quality, safety, and nurse retention can be advanced through a shared governance model. Therefore, there’s a need to bridge the military’s centralized architecture of command and control with the concepts of shared governance to develop collaborative practices that www.nursingmanagement.com
continue to provide quality care to military beneficiaries. Military healthcare facilities are impacted by national nursing shortages to the same degree as civilian facilities. Nurses, with a baccalaureate degree or higher, can choose to serve the country and enlist in the military and, as such, would be recognized as members of the respective branches’ Nurse Corps (Army, Navy, and Air Force). When there are insufficient numbers of active duty nurses, military facilities must competitively enter the common marketplace and recruit qualified nurses for vacant positions. Recruiting and subsequently hiring civilian nurses may be hindered by the complex military/ government hiring procedures. Intermittent hiring freezes for government agencies may compound the hiring process. Often, it takes several months to process the hiring of a civilian nurse into the government system.4 The cost to hire and train a qualified RN in an Army facility can exceed $67,000.5 Retaining nurses becomes extremely important to maintain an adequate nursing workforce and Nursing Management • November 2014 45
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Implementing unit practice councils
reduce costs associated with hiring and training new nurses. Army facilities are pursuing ways to attract and retain a high-quality civilian nursing staff. One way to do this is to implement policies and procedures to increase nurse job satisfaction. Evidence indicates that shared governance can improve job satisfaction and retention of nurses.6,7 This article describes how one Army facility implemented shared governance by creating a unit practice council (UPC) in the primary care department.
Too much turnover The U.S. Army Nurse Corps (ANC) leadership sought to create a new nurse practice model that would generate consistent standards across the Army facilities.5 This decision was sought following identification of an issue that affected nursing practice and contributed to a shortage of nurses in military facilities. Before 2010, nursing practice models for care delivery varied between each Army facility. Each facility’s senior nurse executive (commanding officer) identified and implemented a nursing practice model suited for that institution’s patient population.5 During the tenure of that nurse executive, the nursing department followed the selected practice model. However, the model of nursing care never remained the same for very long because the military routinely rotates personnel every few years. When a new nurse executive arrived at the facility, there was the opportunity to change the practice model. Not only did commanding nurse officers rotate on a regular schedule, so did the active duty personnel, resulting in the need to retrain many individuals. Such rotations created inconsistencies between practice models and
frustration among military and civilian staff members.5
Professional practice model In 2010, the ANC created and implemented a new professional practice model called the Patient Caring Touch System (PCTS) after an extensive review of literature and evaluation of successful military and civilian nursing practice models. The PCTS was designed to be the permanent model of nursing practice for each Army medical institution regardless of changes in nurse leadership and clinical nurse rotations. PCTS consists of five essential domains: enhanced communication, capacity building, evidence-based practice (EBP), healthy work environments, and patient advocacy. The domain of healthy work environment encompasses shared governance and includes two important components: UPCs and nurse practice councils (NPCs).5 Each Army facility is responsible for creating UPCs within the PCTS model.
Planning the process In 2012, a large multiservice outpatient Army facility began work on the UPC component of shared governance. Nurse executive support was in place at this time, as was the NPC, which was designed to serve as the executive nurse governing body. A plan was in place to create the UPCs in a manner that organizationally allowed council members to identify and report both clinical or administrative issues and recommendations to the NPC. The plan also identified that the chair and cochair of the UPCs would become members of the facility’s NPC. Senior nurse leaders were supportive of creating UPCs, which was critical for the UPC and shared governance model of
46 November 2014 • Nursing Management
nursing practice to succeed.8,9 These senior leaders authorized training time for nurses to participate and advertised the initiative at their weekly staff meetings. Senior leadership agreed that the UPC members would be provided paid work time each month for the UPC meeting and additional time, as needed, for researching answers to identified issues. This investment of human and financial resources reinforced the commitment of the leadership team to the UPC initiative. Despite the administrative and executive structure that was in place to support UPC development, the process for creating UPCs hadn’t been determined by the organization. Therefore, a designee with experience in nursing shared governance was asked to assist in implementing the initiative. The designee was a military officer who had previously worked at the facility and had recent experience in shared governance and implementing the PCTS. The designee was given authority from senior nurse executives to create a UPC and his responsibilities included working with key stakeholders and institutional processes and structures to set the foundation for UPC implementation. Planning the initiative included a thorough review of the literature attempting to identify elements of shared governance and UPC implementation that would work at a military clinic. The designee was also charged with any orientation necessary for the UPC to function effectively. Finally, the designee was responsible for determining outcome measures that the facility could use to determine the organizational impact of the UPC initiative.
Creating a blueprint A review of relevant literature was conducted by the designee www.nursingmanagement.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
and several steps were identified that assisted with the implementation of UPCs at this Army facility. The literature review focused on the principles of shared governance that would be applicable to a military healthcare facility. Although many different shared governance models were identified, three core principles emerged: 1. Responsibilities for the delivery of nursing care must reside with the clinical staff. 2. Authority for nurses to act must be recognized by the organization. 3. Accountability for quality patient care and professionalism must be accepted by the clinical staff.10 An essential point in shared governance is that nurses are empowered to address clinical practice issues, identify solutions, and make recommendations to nurse leaders. Clinical nurses are then accountable for implementation of those solutions after leadership approval. Shared governance isn’t merely the supervisor “giving up power” to the employee, rather, it extends the decision making for practice issues to the clinical nurse.10 Further, implementing and maintaining a shared governance model should be considered a process and not a project.10,11 Implementation takes energy, patience, and time, with true integration occurring over 3 to 5 years.12 With these points in mind, a blueprint for UPC implementation was developed and presented to senior nurse leadership. (See Table 1.) The blueprint served as a step-by-step guide for creating UPCs and helped provide progress reports to nursing leadership.13-15 The facility requested the creation of a pilot UPC, at an accelerated schedule, to demonstrate to the ANC that the UPC process at this facility was moving forward in the right direction. With the focus on rapid implementation, the www.nursingmanagement.com
Table 1: Blueprint to UPCs in an Army clinic8-10 Review literature on shared governance and UPC development. Develop a UPC orientation agenda for newly elected UPC members highlighting the advantages of shared governance and framing it within the context of Army nursing. Develop UPC orientation for nurse leaders to communicate the strategic importance of UPC initiative, as well as garner support for their nursing staff members who are also participating. Introduce the UPC chair, cochair, and secretary to the NPC to assist in integration. Facilitate the design of a departmental-level UPC with nursing leadership, including the solicitation of volunteers from each primary care clinic. Propose working UPC bylaws draft for consideration at the first meeting to expedite UPC formation. Coach UPC development of a problem or work list to include assisting in prioritization of issues. Create an educational program for new UPC members on effective functioning of UPC meetings and how to conduct EBP projects. Organize and facilitate one to three meetings with the newly elected UPC chair and cochair. Create a UPC orientation guide for new UPC members in hard copy and digital form.
creation and utilization of a blueprint to drive the UPC development became an important element. The facility’s primary care department was selected as the site of the pilot UPC. The primary care department consisted of five separate clinics that employed more than 50% of all nurses in the facility. Preliminary discussions with the primary care department nursing staff members were conducted to determine whether each clinic would have a UPC or it would be a departmental-level initiative; the latter was selected because collaboration on common issues and solutions is most effective. Nurse volunteers were essential to this program because UPCs are most effective when led by volunteers. Initially, UPC volunteers from the five primary care clinics consisted of RNs and LPNs who were interested in the new initiative at the facility. However, the primary care nursing staff members wanted a true representation of all staff on the UPC;
therefore, the UPC membership was expanded to include unit secretaries and combat medics, who have unique roles in Army medicine. Per the blueprint, an orientation process was developed to provide an overview of shared governance and UPC functions. The orientation process facilitated exchange of feedback from the new UPC members to share ideas on how to move forward and gain ownership of the UPC. Orientation was planned as three separate sessions with distinct learning topics for each session. The plan for the first session was to provide the rationale for the new initiative, history of shared governance, and how the UPC could benefit them. The second orientation session provided more detail on shared governance with relevant examples from the literature. Finally, the goal of the third orientation focused on how the UPC could identify clinical projects and search the literature for relevant, evidence-based solutions.
Nursing Management • November 2014 47
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Implementing unit practice councils
Implementing UPCs The first orientation meeting was essential to lay the foundation for successful implementation of the pilot UPC within the PCTS structure. In order to embrace the new initiative, the volunteer UPC members needed to understand the importance of the UPC and how it would benefit them as professionals. A fundamental point with implementation of a shared governance model was that nursing would have to be more involved with professional practice decisions in this Army facility. The meeting included a discussion of how UPCs can be config-
structure was explained with an emphasis on the scope of the UPC. For instance, the UPC can impact change in nursing practice issues and patient care innovations. By improving nursing practice or implementing patient care innovations, the patients’ and staff members’ experiences at the facility would improve. However, the UPC can’t change, directly, the allocation of resources. For areas outside the scope of the UPC, recommendations can be made for consideration by senior facility leadership. Case studies and examples of successful implementations of shared governance at other federal
The new Army UPC and shared governance structures are in place to make nurse empowerment a reality despite current or future challenges. ured and the presentation of several short Internet videos that explained the role of shared governance in other facilities. Draft bylaws had been created that incorporated items from the facility NPC charter and bylaws from civilian facilities. The group was asked to review the draft bylaws and make recommendations so the bylaws could be voted on at the first meeting that was scheduled several weeks later. During the second orientation session, the UPC designee and UPC members delved deeper into the components of shared governance and reviewed the administrative functions of the UPC. Additionally, the role of the UPC in the facility
facilities were highlighted because there was no published literature on implementation at a military healthcare facility. Continued emphasis on the benefits of the UPC was an important component because this endeavor would involve some additional work for the members. Finally, recommendations were provided on how to run effective, productive meetings. The final orientation meeting was focused on training the new UPC members on EBP for clinical nurses. One of the primary functions of the UPC is to develop EBP solutions to clinical problems that are identified. Because approximately 25% of the UPC was made up of nonnurses
48 November 2014 • Nursing Management
(combat medics and secretaries), the presentation was tailored to incorporate essential elements at a level that all staff members could understand. The agenda items included defining EBP, clinical question formatting, databases to search, identifying study design, evidence hierarchy/evidence tables, and writing an executive summary. This particular medical facility recently closed its medical library, so the UPC members needed to know where and how to search for relevant literature. The Army has an online website that includes free access to databases such as OVID SP, CINAHL, and PubMed. This website also has an online journal access similar to most academic institutions. Executive summary or proposal development was presented so the UPC could provide nurse leaders with a concise, evidence-based recommendation. The goal of this training was to provide the tools and education needed to find answers to clinical questions, not to make them EBP or research experts. Further training has been planned in the near future to reinforce the information presented during these sessions. A UPC orientation guide was developed at the end of the UPC implementation process. The purpose of the guide was to provide a self-study resource to orient new UPC members to the process of shared governance and UPC functioning at Army clinics. The final product has been placed on the ANC shared website, which is accessible to all Army nurses, both civilian and military. This document provides all new UPC volunteers with a common orientation guide to UPC functions.
Process in action The first primary care UPC meeting took place in August 2013. The www.nursingmanagement.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
group established some common meeting rules and agreed on the way to conduct business. Standards were cemented when the group voted for the draft bylaws, making them official. Next, the group voted for and elected a chair, cochair, and secretary to serve as initial leadership. Within a few weeks, the UPC leadership team began attending the facility NPC meeting, integrating the new appointees with the facility’s nursing leadership structure. The first orientation sessions were conducted in July 2013 and completed within the first week of October 2013. The training and initiation process wasn’t without challenges. In July, federal sequestration cuts were initiated, forcing government employees, healthcare staff included, to have one nonpaid day off each week for the remainder of the fiscal year (until October 1, 2013). In September 2013, there was a brief government shutdown but the civilian nursing staff members were deemed essential for the facility to operate. Coordination of the UPC orientation on a compressed scheduled proved to be a significant challenge, but nursing leadership supported the process throughout.
Empowering nurses After UPC initiation, improvement projects were identified quickly. The first project selected by the UPC was to review and provide feedback for the facility’s scope of nursing practice policy. The UPC quickly identified that many aspects of the scope of practice policy were geared toward inpatient nursing. For example, combat medics were excluded from many of the duties that were within their scope of practice. Further, many nursing procedures listed were www.nursingmanagement.com
invasive and more applicable to an inpatient facility. After reviewing applicable Army regulations, state law, and what other Army facilities were doing, revisions were submitted to senior nursing leadership. Currently, those recommendations are being incorporated into a new facility nursing scope of practice. Two months after initiation of the UPC, additional projects were identified with the solicitation of input from staff members working in the clinics. Some initial projects included review of the PCTS standard operating procedures for the clinics, which mandated how the new professional practice model was incorporated into daily operations. Additionally, the UPC has been looking at ways to improve the patient care experience by reviewing patient satisfaction surveys and making evidence-based recommendations to improve the patient experience. Shared governance at Army facilities is new and exciting. Key to its success is the continued support of Army nurse leaders at every facility. A designee was an invaluable resource to work with key stakeholders and institutional structures and processes to build the foundation for UPCs. Challenges will continue to be present, such as new or evolving patient care missions or, perhaps, budget challenges from Washington. However, the new UPC and shared governance structures are in place to make nurse empowerment a reality despite current or future challenges. NM REFERENCES 1. Howell JN, Frederick J, Olinger B, et al. Can nurses govern in a government agency? J Nurs Adm. 2001;31(4):187-195. 2. United States Army Medical Department. AMEDD civilian demographics. https:// ameddciviliancorps.amedd.army.mil/ CivilianCorps.aspx?ID=b626c2f3-797648ea-aa43-eb01785c1e3a.
3. MEDCOM. Personal communication with civilian personnel office, 2013. 4. U.S. Department of Defense. DOD makes progress in civilian hiring reform. http:// www.defense.gov/News/NewsArticle. aspx?ID=63979. 5. Army Nurses Corps. Personal communication with Office of the Chief, Army Nurse Corps, 2013. 6. Stumpf LR. A comparison of governance types and patient satisfaction outcomes. J Nurs Adm. 2001;31(4):196-202. 7. Jones CB, Stasiowski S, Simons BJ, Boyd NJ, Lucas MD. Shared governance and the nursing practice environment. Nurs Econ. 1993;11(4):208-214. 8. Bamford-Wade A, Moss C. Transformational leadership and shared governance: an action study. J Nurs Manag. 2010;18 (7):815-821. 9. Mrayyan MT. Nurses’ autonomy: Influence of nurse managers’ actions. J Adv Nurs. 2004;45(3):326-336. 10. Frith K, Montgomery M. Perceptions, knowledge, and commitment of clinical staff to shared governance. Nurs Adm Q. 2006;30(3):273-284. 11. Porter-O’Grady T. Is shared governance still relevant? J Nurs Adm. 2001;31(10): 468-473. 12. Anthony MK. Shared governance models: the theory, practice, and evidence. Online J Issues Nurs. 2004;9(1):7. 13. Church JA, Baker P, Berry DM. Shared governance: a journey with continual mile markers. Nurs Manage. 2008;39(4):34-40. 14. Hess R. Shared governance: what can it mean for nurses? Nurse.Com. 2013: 30-35. 15. Newman KP. Transforming organizational culture through nursing shared governance. Nurs Clin North Am. 2011;46(1):45-58. At Georgia Regents University College of Nursing in Augusta, Ga, Brad Franklin is a DNP student, Marguerite Murphy is the DNP program director, and Pamela Cook is the assistant dean of Student Services and an associate professor. The authors have disclosed that they have no financial relationships related to this article. Disclaimer: The views expressed in this article are those of the authors and don’t necessarily reflect the official policy or position of the Department of Defense or the Army Medical Department. DOI-10.1097/01.NUMA.0000453937.56010.32
Nursing Management • November 2014 49
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
www.nursingmanagement.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Shared governance in an Army clinic:
Implementing unit practice councils By Brad Franklin, MSN, RN, FNP-C; Marguerite Murphy, DNP, RN; and Pamela Cook, DNP, RN, NE-BC
S
hared governance and Army medicine are two concepts that wouldn’t generally be considered joined together in the spirit of collaboration. The U.S. Army Medical Department and its numerous facilities, like other federal agencies, has a centralized power hierarchy that’s not conducive to sharing authority. Often, such power is a result of federal laws that prohibit local control over certain functions.1 In the military healthcare setting, officers with higher rank usually have more authority to make decisions. Staffing at many military facilities utilize a large civilian work force.2 For Army facilities, 57% of RNs and 67% of LPNs today are civilian and fall outside the military rank system.3 The strong civilian workforce is critical to ensuring quality care for soldiers and their families. Quality, safety, and nurse retention can be advanced through a shared governance model. Therefore, there’s a need to bridge the military’s centralized architecture of command and control with the concepts of shared governance to develop collaborative practices that www.nursingmanagement.com
continue to provide quality care to military beneficiaries. Military healthcare facilities are impacted by national nursing shortages to the same degree as civilian facilities. Nurses, with a baccalaureate degree or higher, can choose to serve the country and enlist in the military and, as such, would be recognized as members of the respective branches’ Nurse Corps (Army, Navy, and Air Force). When there are insufficient numbers of active duty nurses, military facilities must competitively enter the common marketplace and recruit qualified nurses for vacant positions. Recruiting and subsequently hiring civilian nurses may be hindered by the complex military/ government hiring procedures. Intermittent hiring freezes for government agencies may compound the hiring process. Often, it takes several months to process the hiring of a civilian nurse into the government system.4 The cost to hire and train a qualified RN in an Army facility can exceed $67,000.5 Retaining nurses becomes extremely important to maintain an adequate nursing workforce and Nursing Management • November 2014 45
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Implementing unit practice councils
reduce costs associated with hiring and training new nurses. Army facilities are pursuing ways to attract and retain a high-quality civilian nursing staff. One way to do this is to implement policies and procedures to increase nurse job satisfaction. Evidence indicates that shared governance can improve job satisfaction and retention of nurses.6,7 This article describes how one Army facility implemented shared governance by creating a unit practice council (UPC) in the primary care department.
Too much turnover The U.S. Army Nurse Corps (ANC) leadership sought to create a new nurse practice model that would generate consistent standards across the Army facilities.5 This decision was sought following identification of an issue that affected nursing practice and contributed to a shortage of nurses in military facilities. Before 2010, nursing practice models for care delivery varied between each Army facility. Each facility’s senior nurse executive (commanding officer) identified and implemented a nursing practice model suited for that institution’s patient population.5 During the tenure of that nurse executive, the nursing department followed the selected practice model. However, the model of nursing care never remained the same for very long because the military routinely rotates personnel every few years. When a new nurse executive arrived at the facility, there was the opportunity to change the practice model. Not only did commanding nurse officers rotate on a regular schedule, so did the active duty personnel, resulting in the need to retrain many individuals. Such rotations created inconsistencies between practice models and
frustration among military and civilian staff members.5
Professional practice model In 2010, the ANC created and implemented a new professional practice model called the Patient Caring Touch System (PCTS) after an extensive review of literature and evaluation of successful military and civilian nursing practice models. The PCTS was designed to be the permanent model of nursing practice for each Army medical institution regardless of changes in nurse leadership and clinical nurse rotations. PCTS consists of five essential domains: enhanced communication, capacity building, evidence-based practice (EBP), healthy work environments, and patient advocacy. The domain of healthy work environment encompasses shared governance and includes two important components: UPCs and nurse practice councils (NPCs).5 Each Army facility is responsible for creating UPCs within the PCTS model.
Planning the process In 2012, a large multiservice outpatient Army facility began work on the UPC component of shared governance. Nurse executive support was in place at this time, as was the NPC, which was designed to serve as the executive nurse governing body. A plan was in place to create the UPCs in a manner that organizationally allowed council members to identify and report both clinical or administrative issues and recommendations to the NPC. The plan also identified that the chair and cochair of the UPCs would become members of the facility’s NPC. Senior nurse leaders were supportive of creating UPCs, which was critical for the UPC and shared governance model of
46 November 2014 • Nursing Management
nursing practice to succeed.8,9 These senior leaders authorized training time for nurses to participate and advertised the initiative at their weekly staff meetings. Senior leadership agreed that the UPC members would be provided paid work time each month for the UPC meeting and additional time, as needed, for researching answers to identified issues. This investment of human and financial resources reinforced the commitment of the leadership team to the UPC initiative. Despite the administrative and executive structure that was in place to support UPC development, the process for creating UPCs hadn’t been determined by the organization. Therefore, a designee with experience in nursing shared governance was asked to assist in implementing the initiative. The designee was a military officer who had previously worked at the facility and had recent experience in shared governance and implementing the PCTS. The designee was given authority from senior nurse executives to create a UPC and his responsibilities included working with key stakeholders and institutional processes and structures to set the foundation for UPC implementation. Planning the initiative included a thorough review of the literature attempting to identify elements of shared governance and UPC implementation that would work at a military clinic. The designee was also charged with any orientation necessary for the UPC to function effectively. Finally, the designee was responsible for determining outcome measures that the facility could use to determine the organizational impact of the UPC initiative.
Creating a blueprint A review of relevant literature was conducted by the designee www.nursingmanagement.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
and several steps were identified that assisted with the implementation of UPCs at this Army facility. The literature review focused on the principles of shared governance that would be applicable to a military healthcare facility. Although many different shared governance models were identified, three core principles emerged: 1. Responsibilities for the delivery of nursing care must reside with the clinical staff. 2. Authority for nurses to act must be recognized by the organization. 3. Accountability for quality patient care and professionalism must be accepted by the clinical staff.10 An essential point in shared governance is that nurses are empowered to address clinical practice issues, identify solutions, and make recommendations to nurse leaders. Clinical nurses are then accountable for implementation of those solutions after leadership approval. Shared governance isn’t merely the supervisor “giving up power” to the employee, rather, it extends the decision making for practice issues to the clinical nurse.10 Further, implementing and maintaining a shared governance model should be considered a process and not a project.10,11 Implementation takes energy, patience, and time, with true integration occurring over 3 to 5 years.12 With these points in mind, a blueprint for UPC implementation was developed and presented to senior nurse leadership. (See Table 1.) The blueprint served as a step-by-step guide for creating UPCs and helped provide progress reports to nursing leadership.13-15 The facility requested the creation of a pilot UPC, at an accelerated schedule, to demonstrate to the ANC that the UPC process at this facility was moving forward in the right direction. With the focus on rapid implementation, the www.nursingmanagement.com
Table 1: Blueprint to UPCs in an Army clinic8-10 Review literature on shared governance and UPC development. Develop a UPC orientation agenda for newly elected UPC members highlighting the advantages of shared governance and framing it within the context of Army nursing. Develop UPC orientation for nurse leaders to communicate the strategic importance of UPC initiative, as well as garner support for their nursing staff members who are also participating. Introduce the UPC chair, cochair, and secretary to the NPC to assist in integration. Facilitate the design of a departmental-level UPC with nursing leadership, including the solicitation of volunteers from each primary care clinic. Propose working UPC bylaws draft for consideration at the first meeting to expedite UPC formation. Coach UPC development of a problem or work list to include assisting in prioritization of issues. Create an educational program for new UPC members on effective functioning of UPC meetings and how to conduct EBP projects. Organize and facilitate one to three meetings with the newly elected UPC chair and cochair. Create a UPC orientation guide for new UPC members in hard copy and digital form.
creation and utilization of a blueprint to drive the UPC development became an important element. The facility’s primary care department was selected as the site of the pilot UPC. The primary care department consisted of five separate clinics that employed more than 50% of all nurses in the facility. Preliminary discussions with the primary care department nursing staff members were conducted to determine whether each clinic would have a UPC or it would be a departmental-level initiative; the latter was selected because collaboration on common issues and solutions is most effective. Nurse volunteers were essential to this program because UPCs are most effective when led by volunteers. Initially, UPC volunteers from the five primary care clinics consisted of RNs and LPNs who were interested in the new initiative at the facility. However, the primary care nursing staff members wanted a true representation of all staff on the UPC;
therefore, the UPC membership was expanded to include unit secretaries and combat medics, who have unique roles in Army medicine. Per the blueprint, an orientation process was developed to provide an overview of shared governance and UPC functions. The orientation process facilitated exchange of feedback from the new UPC members to share ideas on how to move forward and gain ownership of the UPC. Orientation was planned as three separate sessions with distinct learning topics for each session. The plan for the first session was to provide the rationale for the new initiative, history of shared governance, and how the UPC could benefit them. The second orientation session provided more detail on shared governance with relevant examples from the literature. Finally, the goal of the third orientation focused on how the UPC could identify clinical projects and search the literature for relevant, evidence-based solutions.
Nursing Management • November 2014 47
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Implementing unit practice councils
Implementing UPCs The first orientation meeting was essential to lay the foundation for successful implementation of the pilot UPC within the PCTS structure. In order to embrace the new initiative, the volunteer UPC members needed to understand the importance of the UPC and how it would benefit them as professionals. A fundamental point with implementation of a shared governance model was that nursing would have to be more involved with professional practice decisions in this Army facility. The meeting included a discussion of how UPCs can be config-
structure was explained with an emphasis on the scope of the UPC. For instance, the UPC can impact change in nursing practice issues and patient care innovations. By improving nursing practice or implementing patient care innovations, the patients’ and staff members’ experiences at the facility would improve. However, the UPC can’t change, directly, the allocation of resources. For areas outside the scope of the UPC, recommendations can be made for consideration by senior facility leadership. Case studies and examples of successful implementations of shared governance at other federal
The new Army UPC and shared governance structures are in place to make nurse empowerment a reality despite current or future challenges. ured and the presentation of several short Internet videos that explained the role of shared governance in other facilities. Draft bylaws had been created that incorporated items from the facility NPC charter and bylaws from civilian facilities. The group was asked to review the draft bylaws and make recommendations so the bylaws could be voted on at the first meeting that was scheduled several weeks later. During the second orientation session, the UPC designee and UPC members delved deeper into the components of shared governance and reviewed the administrative functions of the UPC. Additionally, the role of the UPC in the facility
facilities were highlighted because there was no published literature on implementation at a military healthcare facility. Continued emphasis on the benefits of the UPC was an important component because this endeavor would involve some additional work for the members. Finally, recommendations were provided on how to run effective, productive meetings. The final orientation meeting was focused on training the new UPC members on EBP for clinical nurses. One of the primary functions of the UPC is to develop EBP solutions to clinical problems that are identified. Because approximately 25% of the UPC was made up of nonnurses
48 November 2014 • Nursing Management
(combat medics and secretaries), the presentation was tailored to incorporate essential elements at a level that all staff members could understand. The agenda items included defining EBP, clinical question formatting, databases to search, identifying study design, evidence hierarchy/evidence tables, and writing an executive summary. This particular medical facility recently closed its medical library, so the UPC members needed to know where and how to search for relevant literature. The Army has an online website that includes free access to databases such as OVID SP, CINAHL, and PubMed. This website also has an online journal access similar to most academic institutions. Executive summary or proposal development was presented so the UPC could provide nurse leaders with a concise, evidence-based recommendation. The goal of this training was to provide the tools and education needed to find answers to clinical questions, not to make them EBP or research experts. Further training has been planned in the near future to reinforce the information presented during these sessions. A UPC orientation guide was developed at the end of the UPC implementation process. The purpose of the guide was to provide a self-study resource to orient new UPC members to the process of shared governance and UPC functioning at Army clinics. The final product has been placed on the ANC shared website, which is accessible to all Army nurses, both civilian and military. This document provides all new UPC volunteers with a common orientation guide to UPC functions.
Process in action The first primary care UPC meeting took place in August 2013. The www.nursingmanagement.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
group established some common meeting rules and agreed on the way to conduct business. Standards were cemented when the group voted for the draft bylaws, making them official. Next, the group voted for and elected a chair, cochair, and secretary to serve as initial leadership. Within a few weeks, the UPC leadership team began attending the facility NPC meeting, integrating the new appointees with the facility’s nursing leadership structure. The first orientation sessions were conducted in July 2013 and completed within the first week of October 2013. The training and initiation process wasn’t without challenges. In July, federal sequestration cuts were initiated, forcing government employees, healthcare staff included, to have one nonpaid day off each week for the remainder of the fiscal year (until October 1, 2013). In September 2013, there was a brief government shutdown but the civilian nursing staff members were deemed essential for the facility to operate. Coordination of the UPC orientation on a compressed scheduled proved to be a significant challenge, but nursing leadership supported the process throughout.
Empowering nurses After UPC initiation, improvement projects were identified quickly. The first project selected by the UPC was to review and provide feedback for the facility’s scope of nursing practice policy. The UPC quickly identified that many aspects of the scope of practice policy were geared toward inpatient nursing. For example, combat medics were excluded from many of the duties that were within their scope of practice. Further, many nursing procedures listed were www.nursingmanagement.com
invasive and more applicable to an inpatient facility. After reviewing applicable Army regulations, state law, and what other Army facilities were doing, revisions were submitted to senior nursing leadership. Currently, those recommendations are being incorporated into a new facility nursing scope of practice. Two months after initiation of the UPC, additional projects were identified with the solicitation of input from staff members working in the clinics. Some initial projects included review of the PCTS standard operating procedures for the clinics, which mandated how the new professional practice model was incorporated into daily operations. Additionally, the UPC has been looking at ways to improve the patient care experience by reviewing patient satisfaction surveys and making evidence-based recommendations to improve the patient experience. Shared governance at Army facilities is new and exciting. Key to its success is the continued support of Army nurse leaders at every facility. A designee was an invaluable resource to work with key stakeholders and institutional structures and processes to build the foundation for UPCs. Challenges will continue to be present, such as new or evolving patient care missions or, perhaps, budget challenges from Washington. However, the new UPC and shared governance structures are in place to make nurse empowerment a reality despite current or future challenges. NM REFERENCES 1. Howell JN, Frederick J, Olinger B, et al. Can nurses govern in a government agency? J Nurs Adm. 2001;31(4):187-195. 2. United States Army Medical Department. AMEDD civilian demographics. https:// ameddciviliancorps.amedd.army.mil/ CivilianCorps.aspx?ID=b626c2f3-797648ea-aa43-eb01785c1e3a.
3. MEDCOM. Personal communication with civilian personnel office, 2013. 4. U.S. Department of Defense. DOD makes progress in civilian hiring reform. http:// www.defense.gov/News/NewsArticle. aspx?ID=63979. 5. Army Nurses Corps. Personal communication with Office of the Chief, Army Nurse Corps, 2013. 6. Stumpf LR. A comparison of governance types and patient satisfaction outcomes. J Nurs Adm. 2001;31(4):196-202. 7. Jones CB, Stasiowski S, Simons BJ, Boyd NJ, Lucas MD. Shared governance and the nursing practice environment. Nurs Econ. 1993;11(4):208-214. 8. Bamford-Wade A, Moss C. Transformational leadership and shared governance: an action study. J Nurs Manag. 2010;18 (7):815-821. 9. Mrayyan MT. Nurses’ autonomy: Influence of nurse managers’ actions. J Adv Nurs. 2004;45(3):326-336. 10. Frith K, Montgomery M. Perceptions, knowledge, and commitment of clinical staff to shared governance. Nurs Adm Q. 2006;30(3):273-284. 11. Porter-O’Grady T. Is shared governance still relevant? J Nurs Adm. 2001;31(10): 468-473. 12. Anthony MK. Shared governance models: the theory, practice, and evidence. Online J Issues Nurs. 2004;9(1):7. 13. Church JA, Baker P, Berry DM. Shared governance: a journey with continual mile markers. Nurs Manage. 2008;39(4):34-40. 14. Hess R. Shared governance: what can it mean for nurses? Nurse.Com. 2013: 30-35. 15. Newman KP. Transforming organizational culture through nursing shared governance. Nurs Clin North Am. 2011;46(1):45-58. At Georgia Regents University College of Nursing in Augusta, Ga, Brad Franklin is a DNP student, Marguerite Murphy is the DNP program director, and Pamela Cook is the assistant dean of Student Services and an associate professor. The authors have disclosed that they have no financial relationships related to this article. Disclaimer: The views expressed in this article are those of the authors and don’t necessarily reflect the official policy or position of the Department of Defense or the Army Medical Department. DOI-10.1097/01.NUMA.0000453937.56010.32
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