Joseph & Bogue, Measures and Theory for Advancing Nursing Shared Governance, MNRS Chicago 030813

2. Midwest Nursing Research Society ● Chicago, IL ● March 7-10, 2013
THEORY AND MEASURES FOR ACCELERATING THE
PRACTICE OF NURSING SHARED GOVERNANCE:
GEMS
M. Lindell Joseph, PhD, RN
Richard J. Bogue, PhD, FACHE
UNIVERSITY OF IOWA
COLLEGE OF NURSING
IOWA CITY, IOWA

3. Midwest Nursing Research Society ● Chicago, IL ● March 7-10, 2013
Objectives
After this presentation, participants will be able to…
1. Discuss inputs, processes, and outcomes of nursing
shared governance
2. Conceive empirical tests of GEMS a formal theory
of nursing shared governance
3. Critique and advance theory, measurement and
practice in nursing shared governance

4. Midwest Nursing Research Society ● Chicago, IL ● March 7-10, 2013
State of Evidence on Shared Governance
1. What about effectiveness?
2. Seen as a pathway to excellence
3. Yet ‘cannot be researched directly’
a. Variations in definitions, measures and units
b. Lack of clarity about process
c. Inconsistent findings on outcomes
4. Field needs a stronger theory-practice link
5. NPCs are a concrete expression of nursing
shared governance

5. Midwest Nursing Research Society ● Chicago, IL ● March 7-10, 2013
Study 1. Defining Empowerment for Teams
NPCes: Initial Evidence on Reliability

6. Midwest Nursing Research Society ● Chicago, IL ● March 7-10, 2013
Study 1. Defining Empowerment for Teams…
in a Multi-Level Organizational Context
More
Empowered
Nurses
(67%)
ORGANIZATIONALVALUES
Information & Extra-Unit Collaboration
(23.90% of variance)
PERSONAL GROWTHVALUES
Opportunity & Support
(23.82% of variance)
UNIT LEVELVALUES
Resources
(19.33 % of variance)

7. Midwest Nursing Research Society ● Chicago, IL ● March 7-10, 2013
Study 2. Defining Empowerment for Leadership
• Group power within organizations Sieloff-King (2003)
– Specific to nursing
– Adds clarity and richness to measurement of empowerment at
organization & department levels
– Group power is the nursing group’s capacity to achieve its
goals. Dimensions of nursing group power include:
• Ability to control environmental forces
• Power from position
• Power from resources
• Power from roles
• Power perspective
• Power competence, and
• CNE communication competency

8. Midwest Nursing Research Society ● Chicago, IL ● March 7-10, 2013
Study 2. Examining Vertical Power & Personality
• Phase I
– Online surveys of factors that may enhance or impede
shared governance at three levels
• Unit Teams: NPC members
• Unit Managers: Nurse Managers & Asst Nurse Managers
• Department & Organization: Nursing Directors and CNOs
• Phase II
– Delphi study with top organizational executives (n=22)

9. Attributions Acting Understanding Feeling
Leadership 3% 30% 9%
Workers 36% 9% 12%
Study 2. Executive Empowerment Philosophy
Executive leadership expected workers to act empowered.
Executive leadership expected of themselves, not action, but understanding.
Midwest Nursing Research Society ● Chicago, IL ● March 7-10, 2013

10. Midwest Nursing Research Society ● Chicago, IL ● March 7-10, 2013
Table 1: External Validation and Outcome Measures Associated with the NPC Effectiveness Scale
r† p‡ St±
ORGANIZATIONAL LEVEL MEASURES
Resources for Goal Attainment (SKAGOAO, Sieloff) 0.562 <0.001 2,3
Organizational Support (POS) 0.563 <0.001 3
Role (nursing central to the organization’s work, SKAGOAO) 0.430 <0.001 2,3
DEPARTMENT LEVEL MEASURES
Position (nursing central in communication network, SKAGOAO) 0.584 <0.001 2,3
CNO Communication Competency (SKAGOAO) 0.435 <0.001 2,3
Nursing Department Group Power (SKAGOAO) 0.505 <0.001 2,3
Control of Environmental Forces (SKAGOAO) 0.599 <0.001 2,3
UNIT LEVEL MEASURES
Structural Empowerment (CWEQ-II) 0.736 <0.001 1
Co-Worker Support (JCQ) 0.431 <0.001 3
Manager Support (JCQ) 0.588 <0.001 3
Pressure Ulcers (NDNQI) ∆ 0.106 3
INDIVIDUAL LEVEL MEASURES
Job Satisfaction (RN Survey) 0.234 0.017 1
Extroversion (40-item Mini Marker Personality Inventory, Saucier) 0.239 0.002 2
Agreeableness (Mini Marker) 0.229 0.003 2
Intellectual Openness (Mini Marker) 0.165 0.037 2
Conscientiousness (Mini Marker) 0.139 0.079 2
Emotional Stability (Mini Marker) 0.114 0.149 2
Self Efficacy (IPIP) 0.200 <0.006 3
†r = Pearson correlation.
‡p = Probability of result, statistical significance
±St refers to Study1, Study2 or Study3.

11. Midwest Nursing Research Society ● Chicago, IL ● March 7-10, 2013
Turnkey tools and processes for Nursing Practice Council Effectiveness and
Organizational Shared Governance
1. NPCs assess themselves and on nine competencies of effective
nursing practice councils
2. Managers and others on the unit also assess NPC
3. Leadership and Teams examine unit & roll-up results for
• performance on the nine competencies
• team dynamics (within a team & vertically)
• vertical alignment in the organization
4. Teams identify one or two competencies to improve
5. Teams use provided evidence-based strategies to support NPC
effectiveness, or invent their own strategies
6. Repeat assessment every six months
Designing & Testing a Process for Empowerment

12. Midwest Nursing Research Society ● Chicago, IL ● March 7-10, 2013
Developing a Theory for Shared Governance
• Identify required
theoretical attributes
for NPC
effectiveness, nursing
group power, and
vertical alignment.
Step 1
• Define each attribute
as an observable
intervention (Critical
Inputs)
Step 2 • Identify the active
ingredients for each
critical input.
Step 3
• Identify expected
outcomes.
Step 4
General EffectivenessTheory for Multilevel Shared Governance
(GEMTheory)

13. Midwest Nursing Research Society ● Chicago, IL ● March 7-10, 2013

14. Nursing LeadershipTeam
Nursing UnitWork Team
Use roles & resources expertly
Manage external forces
Communicate goals
Influence decisions
Self-direct
Align performance
Empower relationships
Empower practices
Build on team foundations
Establish team foundations
GEMS Effective
Shared Governance
Inputs
Inputs
Process
Organization Level
Department Level
Unit Level
Personal Level
Outcomes
Nursing Influence/
Power (SKAGO)
Resources for Goals
(SKAGO)
Mgr Support (JCQ)
Pressure Ulcers
Self Efficacy (IPIP)
Job Sat (NDNQI)

15. Midwest Nursing Research Society ● Chicago, IL ● March 7-10, 2013
Summary and Testable Propositions
• GEMS is process theory for engaging nurses at all levels to strive toward
excellence at their level of competencies and aspirations.
• Maximizing & aligning nurses’ decision-making authority at all levels
reflects true nursing shared governance.
1. Teams rating higher on NPCes will…
a. More quickly and more widely adopt patient safety protocols
b. Achieve higher rates of quality performance improvement
c. Have more satisfied people and less turnover
2. Where leadership rates NPCes higher than care team members do,
shared governance will be more marketing than empowering
3. Where both leadership and teams rate low on NPCes, there will be an
opportunity for a genuine journey forward together
4. Where both leadership and teams rate high on NPCes, there will be
excellence in patient care and nurse engagement

16. Midwest Nursing Research Society ● Chicago, IL ● March 7-10, 2013
General Effectiveness Multilevel Shared Governance
Formalized GEMS, a practical,
measurable, testable multilevel theory
Examined outcomes at individual, unit,
department, organizational levels
Needed a measure of leadership
competencies for empowerment
Needed a process for multilevel
empowerment
Needed a practical, competency-
based measure of team effectiveness

17. Midwest Nursing Research Society ● Chicago, IL ● March 7-10, 2013
References
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Online Journal of Issues in Nursing, 9(1). 3.
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Oxford: University Press.
• Bogue RJ, Joseph ML & Sieloff CL. (2009). Vertical Alignment of Nursing Group Power
and Nurse Practice Council Effectiveness. Journal of Nursing Management, 17:4-14.
• Hess, R., J. (2004). From bedside to boardroom -- nursing shared governance. Online
Journal of Issues in Nursing, 9(1), 10p.
• Joseph, R., Bogue, R., & Thompson, J. (2006). Nursing practice councils: A Formative
Assessment. Research Report. Florida Hospital.
• Kanter, R. (1977). Men and Women of the Corporation. New York: Basic Books.
• Porter-O'Grady, T. (2004). Shared governance: Is it a model for nurses to gain control
over their practice? Online Journal of Issues in Nursing, 9(1), 1.
• Sieloff, C. L. (1995). Development of a theory of departmental power in advancing King’s
systems framework and theory of goal attainment. Sage Publications.
• Saucier, G. (1994). Mini-Markers: A brief version of Goldberg's unipolar Big-Five
markers. Journal of Personality Assessment, 63, 506-516.
• Sieloff, C. L. (2004). Leadership behaviors that foster nursing group power. Journal of
Nursing Management. 12, 246-251.
• Wright, T. A. (2003). What Every Manager Should Know: Does Personality Help Drive
Employee Motivation? The Academy of Management Executive. 17(2). 131.

18. M. Lindell Joseph, PhD, RN
Email: Maria-Joseph@uiowa.edu
Richard J. Bogue, PhD, FACHE
Email: Richard-Bogue@uiowa.edu