Nurses share in pandemic decisionmaking process through professional governance

Like health systems across the country and around the world, Emory Healthcare in Atlanta faced a personal protective equipment shortage when the coronavirus pandemic hit.

The system was running out of gowns and had to decide whether to recycle or wash them. Instead of making that decision themselves, Emory’s leaders turned to their nurses.

“As we were moving through the pandemic, I had really thought about how much are we engaging our front-line clinicians in making decisions about what they do to keep themselves safe,” said Sharon Pappas, chief nurse executive for Emory.

Because Emory has what is called a shared governance or professional governance system in place, nurses already served on unit-, hospital- and system-level governance councils in which they share in decisionmaking. When Pappas directed the gown dilemma to the councils, nurses came together to decide to transition from paper gowns to cloth ones that could be washed.

“To me, that was a wonderful application of professional governance engaging them,” Pappas said. “When people feel in control of decisions, it contributes positively to their well-being. They don’t feel like decisions are being pushed to them.”

Involving nurses in conversations and decisions about patient care, safety, training and operations has helped systems better respond to the coronavirus pandemic in a way that empowers them, even as they tackle unprecedented levels of stress, leaders say.

“These individuals are in the best position to really decide what clinical care should look like,” Pappas said. “It’s our job as clinical leaders to create a work environment where that’s possible.”

Since its introduction a few decades ago, professional governance is now in place at about a quarter of the country’s roughly 4,200 acute-care hospitals, estimated Tim Porter-O’Grady, a nurse and a healthcare consultant who is often referred to as the pioneer of the professional governance model. “It’s still a journey that we’re on,” Porter-O’Grady said. “As much as I’d like to think we’re at a place where we value what each professional brings to the collective, it’s still not fully there.”

The tenets of professional governance are embedded in the American Nurses Credentialing Center’s voluntary Magnet and Pathway to Excellence programs, which recognize healthcare organizations that value and prioritize nursing. At last count, there were 540 Magnet and 192 Pathways to Excellence-recognized hospitals, a number that grows about 10% to 15% each year, according to Rebecca Graystone, vice president of the Magnet Recognition and Pathway to Excellence programs.

“While it is a recognition of nursing excellence, it is a recognition of the entire healthcare organization because of the interprofessional nature of how healthcare is delivered. It’s a recognition of all of those voices,” Graystone said.

Lori Wightman, senior vice president and chief nursing officer for Broomfield, Colo.-based SCL Health, credits the system’s ability to maintain patient quality outcomes and patient satisfaction throughout the pandemic to “caregivers working in a culture that embraces professional governance.”

“We listen to the caregivers in order to understand their needs: to care for patients, for themselves and for each other,” Wightman said.

A study by nurses at the University of Pennsylvania School of Nursing and Pennsylvania Hospital in Philadelphia found that hospitals with more-engaged nurses had better patient experiences, quality of care and nurse job outcomes than those where nurses were less involved in decisionmaking.

The study also makes a business case for professional governance as a way to support value-based care payment models.

“Facing a competitive, value-based purchasing environment and potential staffing shortages, hospitals have a vested interest in promoting a culture of engagement among nurses, who comprise the largest share of the hospital workforce,” the authors wrote.

Examples of how shared governance can improve operational performance vary in approach and organizational size. At Brigham and Women’s Faulkner Hospital in Boston, the nursing practice committee is working to improve communication between leadership and staff. Early on in the pandemic when there were “rapid-fire changes in practice,” those were mostly shared via email, said Colleen West, executive director of nursing professional development, practice and innovation. But nurses didn’t have time to check email as COVID-19 patients flooded in. Now, they’re working with the communications department to find ways to improve internal communications about operations.

The nurse practice council at Memorial Hospital and Health Care Center in Jasper, Ind., is creating a resiliency room (or a relaxation room; the name has yet to be decided). “It’s a space where staff can go to recharge,” said Lori Persohn, vice president of patient services and chief nursing officer at Memorial. COVID-19 has amplified the need for downtime, she said. While plans are still in the works, nurses want to create a quiet space that could have essential oils, peaceful music and a recliner.

Memorial uses its nursing councils as opportunities for career progression, Persohn said. Most of the system’s nurse managers and nursing directors were promoted after gaining leadership experience by participating in unit councils. And council participation is included as part of a nurse’s workday, so there’s not a perception that they have to work longer days to join one. 

The nursing councils have been so successful at Memorial that other departments, like the lab and pharmacy, have adopted the professional governance model, Persohn said. 

“I look at it very simply. It’s staff nurses and leaders working together to problem-solve, create a better working environment and to produce quality outcomes. All of those things increase nursing engagement, in turn retaining our nurses and providing quality of care,” Persohn said.