How 5 CNOs elevate nurses' voices in decision-making

By and large, nurses want to be involved in decisions that affect their daily practice at the bedside, with recent evidence suggesting it may even combat burnout.

A study funded by the Agency for Healthcare Research and Quality suggests nurses who are engaged and involved in quality improvement measures and feel confident in patient experience measures report less burnout. 

As a priority for 2023, Jennifer Mensik, PhD, RN, the new president of the American Nurses Association, encouraged leaders to find ways to elevate nurses' voices. 

"They like autonomy. They like to be involved in decisions," she told Becker's earlier this month. Dr. Mensik prompted leaders to consider how they can get their nursing staff involved in decision-making on a level they may have not been before, to where "they're looking at policies, making decisions on supplies" and what workflows should look like. 

"As opposed to having individuals say, 'Here's what you're gonna do now.' We really need to embody it as a profession," Dr. Mensik said. 

To get a pulse on how leaders support nurse decision-making, Becker's asked five chief nursing officers how their hospitals or health systems are giving nurses a larger role in decision-making regarding workflows or policies that directly affect their daily work. Most underscored the value of shared governance programs as a tool to gather nurses' input and guide changes. 

Editor's note: Responses have been lightly edited for length and clarity. 

Meredith Foxx, MSN, APRN. Executive Chief Nursing Officer of Cleveland Clinic: At Cleveland Clinic, we have shared governance councils across the health system that provide nurses at all levels a platform to share their voices, impact clinical practice, advance nursing excellence, promote job satisfaction and encourage leadership development.   

Our shared governance councils are made up of front-line nurses and nursing support caregivers who work on quality and process improvements, and are directly involved in workflows and policies that affect their day-to-day work.  

We also host an annual Shared Governance Day event, which gives our nurses an opportunity to showcase their projects and ideas. This annual event has resulted in more than 100 projects presented by our nurses before submission to national conferences.

Ryannon Frederick, MSN, RN. Chief Nursing Officer of Mayo Clinic (Rochester, Minn.): Mayo Clinic has a rich history of nursing shared governance. Nurses at Mayo Clinic have been actively supporting shared decision-making about practice and clinical outcomes for more than 20 years through participation on various councils, work groups and committees. Their contributions include improving workflows, initiating quality improvement projects, supporting bidirectional communication, developing and improving policies, creating new care models, identifying and implementing new technologies and transforming healthcare for the benefit of patients and staff. Not only is nursing professional governance deeply embedded in our history, we are constantly working to promote and refine how the nurse influences and leads patient care, nursing practice and drives excellence in the work environment.

Mayo Clinic nurses' expertise, patient-centered approach and outcomes-driven focus, combined with an increased knowledge of technology, data management and virtual care are providing faster solutions for patients and helping transform the professional practice of nursing globally. Nursing's contribution is widely recognized as accelerating our progress toward the preferred future, resulting in better outcomes for patients and a better environment for caregivers.

Jennifer Gentry, MSN, RN. Chief Nursing Officer of Providence's Central Division (Renton, Wash.): With the current national staffing situation, it is incumbent on health system leadership to ensure we are creating space for nurses to have a bigger role in decision-making regarding workflows or policies. As we navigated the pandemic in healthcare, we had to take significant measures to keep staff and patients safe. One of the most impactful measures taken was the elimination of in-person meetings and gatherings. Shared governance councils were moved to virtual meetings and many meetings were canceled to direct all staffing resources to patient care. 

This led to less effective shared governance councils and low participation. As we assessed the status of shared governance across the division, we found significant degradation in the quality of our systems and structures. We also found that many of our councils struggled in the virtual environment. In response to these findings, we are kicking off work to evaluate charters in collaboration with our direct care nurses to ensure we are using time purposely and are focused in the right areas that will bring value to nurses and our patients. We are focused on improving the presence and strength of the unit-based council, removing redundancies, and ensuring we are providing the right information and resources to the councils to empower them to make decisions regarding their practice. In addition, we are investing in our council chairs to ensure they have the skills needed to lead and lead in a virtual or hybrid environment. 

Trish O'Keefe, PhD, RN. Senior Vice President and Chief Nursing Officer of Atlantic Health System (Morristown, N.J.): At Atlantic Health as part of our strategy as well as our culture is to incorporate nursing staff empowerment. What do I mean by that? We have a formal structure across our system. Our staff empowerment structure is our shared governance framework. [The framework] is focused on accountability of our practicing nurse as well as how they frame their practice at the bedside. The tenets for shared governance are staff accountability and involvement in all levels of their practice. 

What falls within shared governance is staff decisions in regards to evidence-based practice that is systemwide, as well as focus on [nurses] particular clinical specialty, such as surgical services, neonatology, cardiac. It's really not a manager sitting down and creating a policy regarding nursing practice. It's our practicing nursing staff that use evidence to create a policy. That's involvement at every single level of the organization. From a structural standpoint with those key tenets, we have a systemwide council model. We have five councils that our staff are represented on and make decisions/policy about across the system. Those councils are nursing practice, nursing quality, nursing professional development, nursing research and work environment. 

Each one of those has a charter to the council. They set annual goals based on the needs of the system and feedback that we receive either from an engagement survey or needs assessment. … That's how goals and feedback are fed into these councils and how they create goals. They're chaired by practicing nursing staff and supported by an administrator to make sure that we've got key linkages to goals and strategies for the system. It's truly developed, created and communicated out by our practicing nursing staff.

A key example would be nursing orientation. That's evaluated by our professional development council. Now, based on COVID, we know the clinical skill sets of new candidates may not be as refined as had been previous to COVID. So [the council] made recommendations on creating a nursing residency as part of the orientation — have longer orientation time, have a good mentorship program. 

Maddy Pearson, DNP, RN. Senior Vice President of Patient Care Services and Chief Nursing Officer of Brigham and Women’s Hospital (Boston): We deeply value the perspective and expertise of our nurses. Nurses have a voice in decision-making through our hospital and department's shared governance structure and committees and councils at the unit and practice level, among other avenues. One recent example of how nurses are shaping the practice environment is by providing input on nursing documentation challenges. This has led to significant changes that will soon be implemented at the Brigham and throughout the Mass General Brigham system to reduce nursing documentation burden while maintaining the highest quality of patient care.

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