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Shared Governance for Nursing
AORN JOURNAL
MARCH 1991, VOL. 53, NO 3
Shared Governance for Nursing PART11: PUTTING THE ORGANIZATION INTO ACTION Tim Porter-O’Grady, RN This is the second part of a two-part article on shared governance. Part I appeared in the February 1991 issue.
I
n part I, the concept and characteristics of shared governance were discussed. This information sets the stage for the specific implications for implementing shared governance. There are several approaches to shared governance; no one model is best. Every organization has its own culture and structures that lead it to construct an approach that works. What emerges, however, should reflect the values identified in this article and in other literature about shared governance. This article discusses the effects of shared governance on the roles of manager and staff. By focusing on the peer process and how relationships change, the change agent can determine the value and approach needed to implement shared governance in surgical services.
Tim Porter-O’Grady, RN, EdD, CS, CNAA, is 694
Surgical services have a unique milieu. The professional values of nursing, however, are as important in this area as anywhere in the hospital. Some administrators complain that operating room nurses are not part of the nursing service and do not exemplify the professional values of nursing. Nothing could be further from the truth. The shared governance approach provides a mechanism for pulling the various nursing specialties together to enter into dialogue regarding issues that affect nurses as a whole and move the profession toward important roles and decisions that affect what nurses do and how they fulfill their roles regardless of the setting. It requires only vision and leadership.
The Manager’s Changing Role
C
learly, the role of the manager grows significantly in shared governance, This person moves from a narrowly defined,
president of a health care consulting f i r m , Affiliated Dynamics, Inc, Atlanta. He also is an assistant professor at Emory University, Atlanta, and a clinical professor at Georgia State University,Atlanta. He received his associate degree in nursing from Lower Columbia College, Longview, Washington; his bachelor of science degree @om Seattle University; his master of science degree in nursing and business f r o m the University of W a s h i n g t o n , Seattle; and his doctorate in higher education @om Nova University,Miami.
AORN JOURNAL
MARCH 1991, VOL. 53, NO 3
Clinical members of the staff usually deal with issues related to the role of the nurse and his or her work. fixed role to a much broader role. The nurse manager becomes moderator of the service process and plays the role of coordinator, integrator, and facilitator of the nursing system within which patient care is offered.‘ While the nursing staff, through its various governance structures, builds the system for nursing practice, the manager ensures that the system works. The manager ensures that the activities required by the system unfold as they should and within the expectations provided for them by the nursing organization and its leadership. When the structures that ensure nursing staff leadership are defined, a rule or bylaw structure often is created to specify and control the system to ensure that no one person can arbitrarily dismantle it without the sanction of the clinical and management leadership. Usually the board of trustees reviews and approves bylaws after the whole nursing staff has agreed on them, and they become the operating rules of the nursing organization. They can be changed or altered only by a two-thirds majority vote of the nursing staff and a validating majority vote of the institution’s board of trustees. In shared governance systems, all activities are under the authority of the major decisionmaking bodies, whether they are clinical or management. They are based on whether the activities are predominantly related to nursing practice or to activities or structures designed to support practice. The manager’s key role is involvement with issues that provide support for practice. Issues related to finance, resource use, staffing, interdepartmental conflicts, and problems with the delivery system fall within the role of the manager. Clinical members of the staff usually deal with issues related to the role of the nurse and his or her work (eg, nursing practice, policy, quality of care, competence, education, peer relations, credential696
ing). Because many of the roles that were the manager’s are now the responsibility of the staff, a different mechanism must ensure that the work gets done. The nursing staff cannot d e p e n d o n m a n a g e r s t o e n s u r e that the nurse’s business gets done. Nursing clinical leadership must develop other mechanisms to address those issues and then ensure appropriate controls t o make them work. T h e majority of the work of shared governance is undertaken in this context.
Restructuring the Organization
E
ven though it may appear in complex organizations that work gets done by accident, actually there are many structures that ensure that service is provided in an orderly and efficient manner. When nursing changes its internal configuration, new structures are required to accomplish patient care. Through the use of councils, congresses, executive bodies, and other clinical forums, much of this work is accomplished. The membership on these clinical decision-making bodies is composed primarily of practicing nurses, supporting clinical specialists, and a nursing administrative representative, who advises the clinical body of constraints and resources in the delivery system that will affect the decisions of the group. Depending on the issue and the shared governance model used, several groups of clinical leaders may make decisions in the best interest of their colleagues and their patients. The chairpeople of these groups are given appropriate powers to make the necessary decisions on behalf of the groups and the nursing staff as a whole, but they are accountable to their peers for their decisions. Through a series of checks and balances, each group communicates its work and the
AORN JOURNAL
MARCH 1991. VOL. 53. NO 3
Peer review in a truly professional organization begins before a nurse becomes a member of the nursing staff. interlocking roles of each group with the others.?
Ensuring Quality
A
s nurses strive toward more professionalism, they are accountable for the quality of nursing practice and the resultant care. They are responsible for themselves, and they have some responsibility for the care delivered by other nurses. Indeed, they are responsible for nurses who collectively deliver nursing care. Because the profession is committed to the care and safety of those it serves, there is a collective responsibility to ensure that care meets expected and defined standards. It is the obligation of the practicing nurse to define care and the standards that articulate it. Because it is a professional obligation, it accrues to the individual and the group. The profession assumes responsibility for the definition of the standard; the individual assumes accountability for practicing within the standard and providing evidence of his or her efficacy or constraint. Formal processes of quality assurance provide a mechanism for measuring the outcomes of care and the activities of the care giver. Neither can unfold independently. Historically, nursing has viewed these processes as separate items. Often, activities associated with them have been assigned to different individuals. Because of regulations that mandate quality assurance processes, the practicing nurse has assumed much of the effort for quality assurance. Issues related to performance review or evaluation, on the other hand, often have been viewed as a management prerogatives and have been developed separately for the review process. They usually are based on a management expectations o r approved j o b descriptions. The manager requests an evalua-
tion on or near the evaluation day, and the nurse endures the manager’s evaluation, or if the manager is enlightened, he or she actually can participate in it. The nurse may receive an acceptable evaluation and may stay another year and may receive an acceptable merit increase. If all is not well, however, the nurse may suffer the slings and arrows of corrective action or suspension, probation, or termination. In effect, this process has virtually nothing to do with ensuring effective care or maintaining an acceptable or extraordinary quality of care. The onus of obligation is directed in the wrong direction by the wrong participants. In a professional organization (eg, hospital), it is not the obligation of the organization to ensure that its members are competent. It is the requisite of membership in the profession that the individual display competency to his or her peers and the organization to remain a member of the staff. He or she does this by meeting the obligations that the organization has defined for the role and by giving evidence of complying with expected standards. Reversing the design of the evaluation system provides the basis for reconnecting the evaluation of the care giver to the assurance of quality of care. Because quality care cannot be ensured by the manager alone, nor can it be attained without assurance of the quality of the care giver, both processes are essential to the delivery of effective care. Only when these two processes are directly connected to each other can the assessment of the quality of care be systematic and complete.
Professional Pi-actice
P
eer review in a truly professional organization begins before a nurse becomes a member of the nursing staff. The criteria for appointment to the nursing staff must be 697
MARCH 1991, VOL. 53. NO 3
clearly defied and rigidly applied. Appointment to the staff of any nursing service should require a staff-driven process that effectively defines an ongoing evaluation process and has an appropriate and effective credentialing and privileging mechanism that operates as a nurse enters the system. In other words, a professional nurse need not apply for a job; rather, consistent with professional behaviors and delineations, he or she seeks the privilege of practicing his or her profession consistent with the requirements established by peers in the setting in which he or she seeks to practice nursing. Several things change in this scenario. The role of the professional ceases to be a “job,” and many of the characteristics of a job also go. Being privileged accrues certain rights and obligations that form part of the expectations of the role. Nurses assume some responsibility for the review of each other, they ensure that a candidate is appropriate for his or her role, and they ensure that mechanisms for appropriate assessment of the candidate’s effectiveness exist. Defining peer activity should not be part of the management process. Even though management plays a role in the peer process, it is neither its exclusive, controlling, or central role. It is staff, through professionally delineated processes, that defines the expectations and enumerates the processes and mechanisms of peer review. If staff members have a role at the outset in the integration of the candidate into nursing practice and the criteria for acceptance is clear, it is logical that an ongoing mechanism defined by the staff must be in place for the continual or periodic review of the contributions of each staff member. When this concept is clear, it is simply a matter of constructing the mechanism for building this process. Some characteristics of the process that guide the development of professionally derived peer review follow. 1. Criteria for membership in the professional staff must be enumerated clearly for both the present staff and candidates. Requirements must be appropriate to performance expectations, and the clinical nursing staff must
AORN JOURNAL
assume leadership in defining clinical criteria and processes for candidate approval. 2. Both credentialing and privileging mechanisms must be part of the quality assurance process, not the standards development process. One mechanism establishes criteria, the other measures its effectiveness and performance. 3. Job orientation is altered for the professional nursing staff. This raises issues of employee roles and orientation. Challenges to personnel questions and institution/person relationships invariably are raised. Hiring practices and review processes undergo thorough discussion and some reformatting that requires a change in perspective, roles, and interaction are determined. 4. Rethinking the nature and role of the nurse in the service setting and the institution is required. Administrators often are concerned about how reclassifications will affect other employees if nursing reformats its role t o reflect its emerging professional character and structure. Other professional bodies within the health care institution will have opinions about nursing reorganizing its internal operating systems to reflect more accountability, authority, autonomy, and control. Both administrators and the medical staff may see a threat to the prevailing authority and hierarchical structures as nurses move into professional practice and governance models that are characteristic of the other professions such as law and medicine. Nursing must be prepared to articulate, justify, and validate the appropriateness of its new structures. It must correlate them to the needs of the nursing staff and use them as the basis for determining and enhancing quality nursing care.
Peer Review
P
er review is the ongoing obligation of every member of the nursing staff. It is used for individual evaluation of nursing practice, and for the collective process of d e f ~ n and g validating quality nursing practice. In this way, the profession maintains its commitment to the quality it has defied for itself and those it serves. 699
AORN JOURNAL
MARCH 1991, VOL. 53, NO 3
The key to effective peer review is centered within the context and quality of the criteria used for assessment. Nurses generally are neophytes in peer-related processes. Because of this, doubt often is expressed about whether such processes are effective and appropriate for nursing. The relatively poor record of medicine in the development and operation of peer-based mechanisms stands, for many, as a monument to the failure of peer-based review of care and the care giver. It must be concluded, however, that such processes probably are not effective for a profession such as medicine whose members are essentially in competition with each other. No evidence is available for professions such as nursing in which members are not in competition with one another and have nothing to gain from placing its members at an advantage or disadvantage. The key to effective peer review is centered within the context and quality of the criteria used for assessment. Historically, the employee evaluation system served as a model for peer review in nursing. The graded performance report served as the evaluation format for most nursing services and identified a range of acceptable performances from barely acceptable to super nurse. It attempted to accomplish something which it clearly was unable to do. It assumed that nurses performed specific criteria with varying degrees of acceptable proficiency and were rewarded directly in proportion to assumed proficiency. In essence, the better a task was done, the higher the reward. The problem was that the assessment of accomplishment was entirely judgmental and subjective. The process was complicated further by the assumption that the manager, who was least prepared to assess the actual day-to-day competency of the practicing nurse, was responsible for determining the proficiency for performance that he or she barely witnessed. If the manager witnessed and participated in the practice process, the message given to the staff, 700
however, was that the evaluation process was management driven and that, although staff input was desirable, the bottom line was that management assessed the level of function of the nurse. This creates two problems. The first relates to the belief that excellence is merely a matter of degree. It postulates that one person does something in an ordinary way, assuming one knows what that is, and another does the same thing in an extraordinary way, again assuming one knows what that is. If the nurse’s work is acceptable, what imperative is there for the nurse to work in any way other than an acceptable manner? More importantly, how would one know whether it was proficient or not with any certainty? Second, acts are completed with the intent that completion achieves the requisite level of appropriateness and contributes to the desired outcome. The act itself should be the best indicator of the level of performance. Either the actor can or cannot accomplish the act at an acceptable level and should be judged on that fact alone. Introducing degrees of proficiency within the act does nothing to justify the value of the act or certify the quality of the actor. What is required in any evaluation system, but especially peer review, is clarity of criteria and an advancement program that clearly defines both role and performance. Criteria-based career advancement programs meet this requirement. Through clear and demonstrable elements of performance, the nurse gives evidence of the quality of his or her work. The accomplishment of the requirements is, by the merit of meeting the requirements alone, the best indicator of the quality of the performance. This is certainly a far more acceptable method of validating performance. It is in this process that the peer evaluation is most promising. Peer review becomes less
AORN JOURNAL
judgmental and more validating. The peer simply certifies what has been accomplished and demonstrated by acknowledging it. Indeed, the manager can more actively and effectively participate in the process because only accomplishment of the requisites is evaluated; the accomplishment itself is the measure of quality. Peer review will become more common as performance criteria become more objective and sophisticated and computerized systems make the accomplishment of criteria more visible. The value of performance review and the peer process is that they assist in developing staff, maintaining appropriate standards of practice, and facilitating the accomplishment of the desired outcomes in care delivery. Any other purpose is short-sighted and of little value. When the process of peer interaction matures in nursing and the systems that support it undergo transition, it will become a source of validation and development more than a process of reward and punishment. When peer review is tied to emerging credentialing and privileging mechanisms, it will offer a real means of ensuring the quality of care and the effectiveness of the care giver.
The Role of the Executive Group
G
enerally, shared governance includes a mechanism for nursing service to make decisions that have implications for all governance entities. This coordinating function usually operates at the executive or highest levels of the organization and brings all the nursing components together for goal setting, evaluation, assignment of functions, and servicewide problem solving. This mechanism usually has representation from the major decision-making bodies in the nursing division, both clinical and management, and is the highest decision-making body in the organization. The chief clinical representative or officer, usually elected to the position by the nursing staff, often chairs this coordinating group. He or she usually is 702
MARCH 1991, VOL. 53,NO 3
a member of the board of trustees.
Summary
S
hared governance is a major departure from traditional management-driven systems. It requires commitment and investment from all of nursing. It builds on the trust developed in the nursing service between all participants who deliver nursing care. It requires management and clinical teams to work closely and redefine their roles. The need for mutual understanding and support is undeniable. Unfortunately, there has not been much reason for that trust to develop at a rate and a level it should in most health care facilities. As institutions move to higher levels of interaction to compete and survive and as the nursing shortage requires hospitals to address the role of the nurse, hospitals are laying the groundwork for nurses to play a larger role in governance and control. These circumstances, among others, stimulate interest and provide a basis on which nurses can work together, whether in management or clinical positions, to strengthen the accountability and role of nurses in managing their services and their practices. Moving to shared governance affects the way in which nurses work and relate to the organization. The use of collective bargaining strategies, movement of the nurse into areas of control over issues that institutions once considered beyond his or her role or right, and conflict management strategies will have to change to facilitate the move of nurses into the mainstream of decision making. As the institution moves from a hierarchical structure to a multiservice setting and a more responsive market-based organization is created, nurses will have to play a stronger role in marketing and managing their practices. This flexibility extends to moving health care services out of the institution and into the community and the home and requiring nurses to become more invested in processes and mechanisms that affect what they do and how they do it. If nurses are to have a place in creating poli-
MARCH 1991, VOL. 53, NO 3
cies and define their part in unfolding the future of health care, they must be able to reorganize their services, create stronger peer-based governance approaches, and exhibit stronger control in the exercise of their practices. That will not happen by accident, nor will there be many people from other disciplines who will be heralding this cause for nurses. Before others in policy-making positions move over to provide the necessary space for nurses, the practicing nurse will have to operate and manage his or her practice at the same level and in a similar manner as other professional workers who are outside of the typical dependent, vocational employee r0le.3 Change must be valid and make sense to be supported. These changes will require more effort on the part of nurses to get their internal house in order at several levels and that they become well-defined, well-structured, and clear about their roles and expectations in the delivery of health services. Shared governance structures provide an integrated and effective vehicle to do this and move nurses to acceptable levels of representation in health care delivery. Notes 1 . J Naisbitt, P Aburdene, Reinventing the Corporation (New York City: Warner Books, 1985). 2. T Porter-O’Grady, S Finnigan, Shared Governance for Nursing: A Creative Approach to Professional Accountability (Rockville, Md: Aspen Systems Corp, 1984) 3. R H Hayes, R Jaikumar, “Manufacturing’s crisis: New technologies,obsolete organizations,” Harvard Business Review 66 (September/October, 1988) 77-85. Suggested reading Pinkerton, S E; Schroeder, P. Commitment to Excellence: Developing a Professional Nursing S t a ~ .Rockville, Md: Aspen Publishers, Inc, 1988. Porter-O’Grady, T. Creative Nursing Administration: Participative Management into the 21 st Century. Rockville, Md: Aspen Systems Corp, 1986.
AORN JOURNAL
More Laser Incidents Reported The Food and Drug Administration’s (FDA) Medical Device Reporting System recorded 20 laser-related incidents during the first half of 1990. Seven of those resulted in injuries including four deaths. Twenty laser-related incidents, including three deaths, were reported during all of 1989. These statistics were reported in the Fall 1990 issue of Laser Nursing. The article stresses the fact that these statistics should not be considered a complete accounting of all medical laser-related incidents. Interpretation should be cautious. It may fist appear that 1990 was a bad year for laser accidents. This increase, however, may be the natural result of more laser procedures. There is no thorough data on the number of laser procedures performed, but estimates from several studies state that laser procedures are still increasing at a rate of thousands each year. This does not rule out the possibility that lasers have become so common that safety precautions are not taken as seriously as they should be. The article also states that a significant percentage of laser incidents resulted from mechanical malfunctions and are not a result of safety problems. In addition to the seven deaths reported for the 18-month period from January 1989 to June 1990, there were 12 serious injuries, two minor injuries, and 19 incidents with no injuries. Organhessel perforation and air embolism were the most frequent type of injury. The patient was injured in 20 of the 21 cases that produced injuries. Thirty-eight of the 40 total incidents occurred during treatment. The other two incidents occurred during maintenance or testing. The gynecology specialty reported 10 of the incidents, eight were from urology, five from otorhinolaryngology, four from ophthalmology, two from general surgery, and one from cardiovascular procedures. The type of procedure was not specified in the remaining 10 cases. 703
MARCH 1991, VOL. 53, NO 3
Shared Governance for Nursing PART11: PUTTING THE ORGANIZATION INTO ACTION Tim Porter-O’Grady, RN This is the second part of a two-part article on shared governance. Part I appeared in the February 1991 issue.
I
n part I, the concept and characteristics of shared governance were discussed. This information sets the stage for the specific implications for implementing shared governance. There are several approaches to shared governance; no one model is best. Every organization has its own culture and structures that lead it to construct an approach that works. What emerges, however, should reflect the values identified in this article and in other literature about shared governance. This article discusses the effects of shared governance on the roles of manager and staff. By focusing on the peer process and how relationships change, the change agent can determine the value and approach needed to implement shared governance in surgical services.
Tim Porter-O’Grady, RN, EdD, CS, CNAA, is 694
Surgical services have a unique milieu. The professional values of nursing, however, are as important in this area as anywhere in the hospital. Some administrators complain that operating room nurses are not part of the nursing service and do not exemplify the professional values of nursing. Nothing could be further from the truth. The shared governance approach provides a mechanism for pulling the various nursing specialties together to enter into dialogue regarding issues that affect nurses as a whole and move the profession toward important roles and decisions that affect what nurses do and how they fulfill their roles regardless of the setting. It requires only vision and leadership.
The Manager’s Changing Role
C
learly, the role of the manager grows significantly in shared governance, This person moves from a narrowly defined,
president of a health care consulting f i r m , Affiliated Dynamics, Inc, Atlanta. He also is an assistant professor at Emory University, Atlanta, and a clinical professor at Georgia State University,Atlanta. He received his associate degree in nursing from Lower Columbia College, Longview, Washington; his bachelor of science degree @om Seattle University; his master of science degree in nursing and business f r o m the University of W a s h i n g t o n , Seattle; and his doctorate in higher education @om Nova University,Miami.
AORN JOURNAL
MARCH 1991, VOL. 53, NO 3
Clinical members of the staff usually deal with issues related to the role of the nurse and his or her work. fixed role to a much broader role. The nurse manager becomes moderator of the service process and plays the role of coordinator, integrator, and facilitator of the nursing system within which patient care is offered.‘ While the nursing staff, through its various governance structures, builds the system for nursing practice, the manager ensures that the system works. The manager ensures that the activities required by the system unfold as they should and within the expectations provided for them by the nursing organization and its leadership. When the structures that ensure nursing staff leadership are defined, a rule or bylaw structure often is created to specify and control the system to ensure that no one person can arbitrarily dismantle it without the sanction of the clinical and management leadership. Usually the board of trustees reviews and approves bylaws after the whole nursing staff has agreed on them, and they become the operating rules of the nursing organization. They can be changed or altered only by a two-thirds majority vote of the nursing staff and a validating majority vote of the institution’s board of trustees. In shared governance systems, all activities are under the authority of the major decisionmaking bodies, whether they are clinical or management. They are based on whether the activities are predominantly related to nursing practice or to activities or structures designed to support practice. The manager’s key role is involvement with issues that provide support for practice. Issues related to finance, resource use, staffing, interdepartmental conflicts, and problems with the delivery system fall within the role of the manager. Clinical members of the staff usually deal with issues related to the role of the nurse and his or her work (eg, nursing practice, policy, quality of care, competence, education, peer relations, credential696
ing). Because many of the roles that were the manager’s are now the responsibility of the staff, a different mechanism must ensure that the work gets done. The nursing staff cannot d e p e n d o n m a n a g e r s t o e n s u r e that the nurse’s business gets done. Nursing clinical leadership must develop other mechanisms to address those issues and then ensure appropriate controls t o make them work. T h e majority of the work of shared governance is undertaken in this context.
Restructuring the Organization
E
ven though it may appear in complex organizations that work gets done by accident, actually there are many structures that ensure that service is provided in an orderly and efficient manner. When nursing changes its internal configuration, new structures are required to accomplish patient care. Through the use of councils, congresses, executive bodies, and other clinical forums, much of this work is accomplished. The membership on these clinical decision-making bodies is composed primarily of practicing nurses, supporting clinical specialists, and a nursing administrative representative, who advises the clinical body of constraints and resources in the delivery system that will affect the decisions of the group. Depending on the issue and the shared governance model used, several groups of clinical leaders may make decisions in the best interest of their colleagues and their patients. The chairpeople of these groups are given appropriate powers to make the necessary decisions on behalf of the groups and the nursing staff as a whole, but they are accountable to their peers for their decisions. Through a series of checks and balances, each group communicates its work and the
AORN JOURNAL
MARCH 1991. VOL. 53. NO 3
Peer review in a truly professional organization begins before a nurse becomes a member of the nursing staff. interlocking roles of each group with the others.?
Ensuring Quality
A
s nurses strive toward more professionalism, they are accountable for the quality of nursing practice and the resultant care. They are responsible for themselves, and they have some responsibility for the care delivered by other nurses. Indeed, they are responsible for nurses who collectively deliver nursing care. Because the profession is committed to the care and safety of those it serves, there is a collective responsibility to ensure that care meets expected and defined standards. It is the obligation of the practicing nurse to define care and the standards that articulate it. Because it is a professional obligation, it accrues to the individual and the group. The profession assumes responsibility for the definition of the standard; the individual assumes accountability for practicing within the standard and providing evidence of his or her efficacy or constraint. Formal processes of quality assurance provide a mechanism for measuring the outcomes of care and the activities of the care giver. Neither can unfold independently. Historically, nursing has viewed these processes as separate items. Often, activities associated with them have been assigned to different individuals. Because of regulations that mandate quality assurance processes, the practicing nurse has assumed much of the effort for quality assurance. Issues related to performance review or evaluation, on the other hand, often have been viewed as a management prerogatives and have been developed separately for the review process. They usually are based on a management expectations o r approved j o b descriptions. The manager requests an evalua-
tion on or near the evaluation day, and the nurse endures the manager’s evaluation, or if the manager is enlightened, he or she actually can participate in it. The nurse may receive an acceptable evaluation and may stay another year and may receive an acceptable merit increase. If all is not well, however, the nurse may suffer the slings and arrows of corrective action or suspension, probation, or termination. In effect, this process has virtually nothing to do with ensuring effective care or maintaining an acceptable or extraordinary quality of care. The onus of obligation is directed in the wrong direction by the wrong participants. In a professional organization (eg, hospital), it is not the obligation of the organization to ensure that its members are competent. It is the requisite of membership in the profession that the individual display competency to his or her peers and the organization to remain a member of the staff. He or she does this by meeting the obligations that the organization has defined for the role and by giving evidence of complying with expected standards. Reversing the design of the evaluation system provides the basis for reconnecting the evaluation of the care giver to the assurance of quality of care. Because quality care cannot be ensured by the manager alone, nor can it be attained without assurance of the quality of the care giver, both processes are essential to the delivery of effective care. Only when these two processes are directly connected to each other can the assessment of the quality of care be systematic and complete.
Professional Pi-actice
P
eer review in a truly professional organization begins before a nurse becomes a member of the nursing staff. The criteria for appointment to the nursing staff must be 697
MARCH 1991, VOL. 53. NO 3
clearly defied and rigidly applied. Appointment to the staff of any nursing service should require a staff-driven process that effectively defines an ongoing evaluation process and has an appropriate and effective credentialing and privileging mechanism that operates as a nurse enters the system. In other words, a professional nurse need not apply for a job; rather, consistent with professional behaviors and delineations, he or she seeks the privilege of practicing his or her profession consistent with the requirements established by peers in the setting in which he or she seeks to practice nursing. Several things change in this scenario. The role of the professional ceases to be a “job,” and many of the characteristics of a job also go. Being privileged accrues certain rights and obligations that form part of the expectations of the role. Nurses assume some responsibility for the review of each other, they ensure that a candidate is appropriate for his or her role, and they ensure that mechanisms for appropriate assessment of the candidate’s effectiveness exist. Defining peer activity should not be part of the management process. Even though management plays a role in the peer process, it is neither its exclusive, controlling, or central role. It is staff, through professionally delineated processes, that defines the expectations and enumerates the processes and mechanisms of peer review. If staff members have a role at the outset in the integration of the candidate into nursing practice and the criteria for acceptance is clear, it is logical that an ongoing mechanism defined by the staff must be in place for the continual or periodic review of the contributions of each staff member. When this concept is clear, it is simply a matter of constructing the mechanism for building this process. Some characteristics of the process that guide the development of professionally derived peer review follow. 1. Criteria for membership in the professional staff must be enumerated clearly for both the present staff and candidates. Requirements must be appropriate to performance expectations, and the clinical nursing staff must
AORN JOURNAL
assume leadership in defining clinical criteria and processes for candidate approval. 2. Both credentialing and privileging mechanisms must be part of the quality assurance process, not the standards development process. One mechanism establishes criteria, the other measures its effectiveness and performance. 3. Job orientation is altered for the professional nursing staff. This raises issues of employee roles and orientation. Challenges to personnel questions and institution/person relationships invariably are raised. Hiring practices and review processes undergo thorough discussion and some reformatting that requires a change in perspective, roles, and interaction are determined. 4. Rethinking the nature and role of the nurse in the service setting and the institution is required. Administrators often are concerned about how reclassifications will affect other employees if nursing reformats its role t o reflect its emerging professional character and structure. Other professional bodies within the health care institution will have opinions about nursing reorganizing its internal operating systems to reflect more accountability, authority, autonomy, and control. Both administrators and the medical staff may see a threat to the prevailing authority and hierarchical structures as nurses move into professional practice and governance models that are characteristic of the other professions such as law and medicine. Nursing must be prepared to articulate, justify, and validate the appropriateness of its new structures. It must correlate them to the needs of the nursing staff and use them as the basis for determining and enhancing quality nursing care.
Peer Review
P
er review is the ongoing obligation of every member of the nursing staff. It is used for individual evaluation of nursing practice, and for the collective process of d e f ~ n and g validating quality nursing practice. In this way, the profession maintains its commitment to the quality it has defied for itself and those it serves. 699
AORN JOURNAL
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The key to effective peer review is centered within the context and quality of the criteria used for assessment. Nurses generally are neophytes in peer-related processes. Because of this, doubt often is expressed about whether such processes are effective and appropriate for nursing. The relatively poor record of medicine in the development and operation of peer-based mechanisms stands, for many, as a monument to the failure of peer-based review of care and the care giver. It must be concluded, however, that such processes probably are not effective for a profession such as medicine whose members are essentially in competition with each other. No evidence is available for professions such as nursing in which members are not in competition with one another and have nothing to gain from placing its members at an advantage or disadvantage. The key to effective peer review is centered within the context and quality of the criteria used for assessment. Historically, the employee evaluation system served as a model for peer review in nursing. The graded performance report served as the evaluation format for most nursing services and identified a range of acceptable performances from barely acceptable to super nurse. It attempted to accomplish something which it clearly was unable to do. It assumed that nurses performed specific criteria with varying degrees of acceptable proficiency and were rewarded directly in proportion to assumed proficiency. In essence, the better a task was done, the higher the reward. The problem was that the assessment of accomplishment was entirely judgmental and subjective. The process was complicated further by the assumption that the manager, who was least prepared to assess the actual day-to-day competency of the practicing nurse, was responsible for determining the proficiency for performance that he or she barely witnessed. If the manager witnessed and participated in the practice process, the message given to the staff, 700
however, was that the evaluation process was management driven and that, although staff input was desirable, the bottom line was that management assessed the level of function of the nurse. This creates two problems. The first relates to the belief that excellence is merely a matter of degree. It postulates that one person does something in an ordinary way, assuming one knows what that is, and another does the same thing in an extraordinary way, again assuming one knows what that is. If the nurse’s work is acceptable, what imperative is there for the nurse to work in any way other than an acceptable manner? More importantly, how would one know whether it was proficient or not with any certainty? Second, acts are completed with the intent that completion achieves the requisite level of appropriateness and contributes to the desired outcome. The act itself should be the best indicator of the level of performance. Either the actor can or cannot accomplish the act at an acceptable level and should be judged on that fact alone. Introducing degrees of proficiency within the act does nothing to justify the value of the act or certify the quality of the actor. What is required in any evaluation system, but especially peer review, is clarity of criteria and an advancement program that clearly defines both role and performance. Criteria-based career advancement programs meet this requirement. Through clear and demonstrable elements of performance, the nurse gives evidence of the quality of his or her work. The accomplishment of the requirements is, by the merit of meeting the requirements alone, the best indicator of the quality of the performance. This is certainly a far more acceptable method of validating performance. It is in this process that the peer evaluation is most promising. Peer review becomes less
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judgmental and more validating. The peer simply certifies what has been accomplished and demonstrated by acknowledging it. Indeed, the manager can more actively and effectively participate in the process because only accomplishment of the requisites is evaluated; the accomplishment itself is the measure of quality. Peer review will become more common as performance criteria become more objective and sophisticated and computerized systems make the accomplishment of criteria more visible. The value of performance review and the peer process is that they assist in developing staff, maintaining appropriate standards of practice, and facilitating the accomplishment of the desired outcomes in care delivery. Any other purpose is short-sighted and of little value. When the process of peer interaction matures in nursing and the systems that support it undergo transition, it will become a source of validation and development more than a process of reward and punishment. When peer review is tied to emerging credentialing and privileging mechanisms, it will offer a real means of ensuring the quality of care and the effectiveness of the care giver.
The Role of the Executive Group
G
enerally, shared governance includes a mechanism for nursing service to make decisions that have implications for all governance entities. This coordinating function usually operates at the executive or highest levels of the organization and brings all the nursing components together for goal setting, evaluation, assignment of functions, and servicewide problem solving. This mechanism usually has representation from the major decision-making bodies in the nursing division, both clinical and management, and is the highest decision-making body in the organization. The chief clinical representative or officer, usually elected to the position by the nursing staff, often chairs this coordinating group. He or she usually is 702
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a member of the board of trustees.
Summary
S
hared governance is a major departure from traditional management-driven systems. It requires commitment and investment from all of nursing. It builds on the trust developed in the nursing service between all participants who deliver nursing care. It requires management and clinical teams to work closely and redefine their roles. The need for mutual understanding and support is undeniable. Unfortunately, there has not been much reason for that trust to develop at a rate and a level it should in most health care facilities. As institutions move to higher levels of interaction to compete and survive and as the nursing shortage requires hospitals to address the role of the nurse, hospitals are laying the groundwork for nurses to play a larger role in governance and control. These circumstances, among others, stimulate interest and provide a basis on which nurses can work together, whether in management or clinical positions, to strengthen the accountability and role of nurses in managing their services and their practices. Moving to shared governance affects the way in which nurses work and relate to the organization. The use of collective bargaining strategies, movement of the nurse into areas of control over issues that institutions once considered beyond his or her role or right, and conflict management strategies will have to change to facilitate the move of nurses into the mainstream of decision making. As the institution moves from a hierarchical structure to a multiservice setting and a more responsive market-based organization is created, nurses will have to play a stronger role in marketing and managing their practices. This flexibility extends to moving health care services out of the institution and into the community and the home and requiring nurses to become more invested in processes and mechanisms that affect what they do and how they do it. If nurses are to have a place in creating poli-
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cies and define their part in unfolding the future of health care, they must be able to reorganize their services, create stronger peer-based governance approaches, and exhibit stronger control in the exercise of their practices. That will not happen by accident, nor will there be many people from other disciplines who will be heralding this cause for nurses. Before others in policy-making positions move over to provide the necessary space for nurses, the practicing nurse will have to operate and manage his or her practice at the same level and in a similar manner as other professional workers who are outside of the typical dependent, vocational employee r0le.3 Change must be valid and make sense to be supported. These changes will require more effort on the part of nurses to get their internal house in order at several levels and that they become well-defined, well-structured, and clear about their roles and expectations in the delivery of health services. Shared governance structures provide an integrated and effective vehicle to do this and move nurses to acceptable levels of representation in health care delivery. Notes 1 . J Naisbitt, P Aburdene, Reinventing the Corporation (New York City: Warner Books, 1985). 2. T Porter-O’Grady, S Finnigan, Shared Governance for Nursing: A Creative Approach to Professional Accountability (Rockville, Md: Aspen Systems Corp, 1984) 3. R H Hayes, R Jaikumar, “Manufacturing’s crisis: New technologies,obsolete organizations,” Harvard Business Review 66 (September/October, 1988) 77-85. Suggested reading Pinkerton, S E; Schroeder, P. Commitment to Excellence: Developing a Professional Nursing S t a ~ .Rockville, Md: Aspen Publishers, Inc, 1988. Porter-O’Grady, T. Creative Nursing Administration: Participative Management into the 21 st Century. Rockville, Md: Aspen Systems Corp, 1986.
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More Laser Incidents Reported The Food and Drug Administration’s (FDA) Medical Device Reporting System recorded 20 laser-related incidents during the first half of 1990. Seven of those resulted in injuries including four deaths. Twenty laser-related incidents, including three deaths, were reported during all of 1989. These statistics were reported in the Fall 1990 issue of Laser Nursing. The article stresses the fact that these statistics should not be considered a complete accounting of all medical laser-related incidents. Interpretation should be cautious. It may fist appear that 1990 was a bad year for laser accidents. This increase, however, may be the natural result of more laser procedures. There is no thorough data on the number of laser procedures performed, but estimates from several studies state that laser procedures are still increasing at a rate of thousands each year. This does not rule out the possibility that lasers have become so common that safety precautions are not taken as seriously as they should be. The article also states that a significant percentage of laser incidents resulted from mechanical malfunctions and are not a result of safety problems. In addition to the seven deaths reported for the 18-month period from January 1989 to June 1990, there were 12 serious injuries, two minor injuries, and 19 incidents with no injuries. Organhessel perforation and air embolism were the most frequent type of injury. The patient was injured in 20 of the 21 cases that produced injuries. Thirty-eight of the 40 total incidents occurred during treatment. The other two incidents occurred during maintenance or testing. The gynecology specialty reported 10 of the incidents, eight were from urology, five from otorhinolaryngology, four from ophthalmology, two from general surgery, and one from cardiovascular procedures. The type of procedure was not specified in the remaining 10 cases. 703