Shared governance and shared leadership: meeting the challenges of implementation

Fostering collective leadership to improve integrated primary care: lessons learned from the PriCARE program

Case management (CM) is an intervention for improving integrated care for patients with complex care needs. The implementation of this complex intervention often raises opportunities for change and collective leadership has the potential to optimize the implementation. However, the application of collective leadership in real-world is not often described in the literature. This commentary highlights challenges faced during the implantation of a CM intervention in primary care for people with complex care needs, including stakeholders' buy-in and providers' willingness to change their practice, selection of the best person for the case manager position and staff turnover. Based on lessons learned from PriCARE research program, this paper encourages researchers to adopt collective leadership strategies for the implementation of complex interventions, including promoting a collaborative approach, fostering stakeholders' engagement in a trusting and fair environment, providing a high level of communication, and enhancing collective leadership attitudes and skills. The learnings from the PriCARE program may help guide researchers for implementing complex healthcare interventions.

Organisational support for healthcare innovation in hospitals: Towards a commitment framework

The article investigates organisational drivers and restrainers of innovation in hospitals on the background of different institutional logics. It presents evidence from a multiple case study in Polish hospitals, which reveals different dynamics on the micro-, meso- and macro-level of organisations in enabling and implementing new procedures and technologies. In particular, the study documents an ambiguous influence of medical professionalism as a specific logic in the healthcare sector, which can affect innovation positively as well as negatively. The article therefore proposes a managerial framework based in innovation action commitment to control the effects of professionalism in healthcare.

Transformational Leadership and Perceived Overqualification: A Career Development Perspective

Drawing on social information processing theory and a career development perspective, we examined the effect of transformational leadership on the perceived overqualification via career growth opportunities, and how the supervisor–subordinate guanxi moderates the relationship between transformational leadership and perceived overqualification. We tested this proposal using three waves of lagged data collected from 351 company employees in the Yangtze River Delta region in China. The results revealed that transformational leadership had an indirect effect on perceived overqualification through career growth opportunities, and supervisor–subordinate guanxi moderated the positive association between transformational leadership and career growth opportunities. In addition, the mediating effect of transformational leadership on perceived overqualification through career growth opportunities was stronger when the level of supervisor–subordinate guanxi was high and weaker when it was low. The findings have theoretical and practical implications for reducing employees’ perceptions of overqualification in the organizational context.

What components are important for effective healthcare alliance governance? Findings from a modified Delphi study in New Zealand

Alliance governance is a form of governance developed in industry settings and more recently applied to healthcare. The core idea behind alliance governance is to involve the many stakeholders in the system to collaboratively develop a joint programme that promotes an integrated and whole of systems approach to care. Little is known about the model in healthcare, nor what those involved in an alliance should be focused upon. Using a modified Delphi method, this research presents a set of components that research participants agreed should underpin development of an effective alliance governance arrangement. These characteristics include a systems perspective-a truly shared governance protocol based on a shared vision and a common purpose; performance measurement-collecting and using real-time data that depicts the realities of an end-to-end system to establish better and more achievable goals based on alliance performance; a relational perspective to promote trust, respect and collaboration amongst alliance members, who historically have been competing for contracts and resources; structural changes that enable and promote a shared governance system; and, finally, equity and inclusion to ensure a diverse alliance which promotes diversity of ideas, and involvement of all stakeholders in the decision making process. This research is relevant to policymakers seeking to develop effective alliance-type arrangements as well as to those involved in the practice of alliance governance.

Challenges and success strategies for dyad leadership model in healthcare

The use of a dyad leadership model involving a physician co-leader and a co-leader with a different background, the dyad co-leader, is gradually increasing in Healthcare Organizations (HCOs). There is a paucity of empirical studies on various aspects of this model. This study's aim was to identify challenges and strategies for success in the dyad leadership model in healthcare. Through a mixed-methods approach utilizing focus groups, surveys, and semi-structured interviews, perceptions of 37 leaders in one HCO at different hierarchical levels were analysed based on their lived experiences. The challenges and success strategies spanned personal, interpersonal, and organizational domains. The areas requiring attention included mindsets, competencies, interpersonal relationship, support, time, communication, and collaboration. In addition, the importance of organizational context addressing its structure, strategy, operations, and culture was highlighted. The findings from this study may be used for praxis, development, and implementation of dyad leadership.

Perception of Shared Governance Among Registered Nurses in Ambulatory Care Center at a Tertiary Care Hospital in Saudi Arabia

Background

Shared governance is considered a model for mounting autonomous decision making in nursing profession and practice. This study aimed to assess how registered nurses in an outpatient department in a tertiary care hospital perceive shared governance.

Methods

We conducted a cross-sectional study among a convenient sample of registered nurses in an outpatient department. A self-administered, Index of Professional Nursing Governance (IPNG) questionnaire was used to measure the study outcome. A descriptive analysis was used to describe nurses' characteristics and study outcomes.

Results

A total of 186 nurses completed the questionnaire. Of whom, 151 (92.1%) were female, and 78 (47.3%) were aged between 20 and 30 years. Only 54 (29.3%) and 59 (31.7%) had indicated a shared decision in terms of controls and influence scales, respectively. The majority of the nurses indicated traditional shared across shared governance scales except in the access information scale.

Conclusion

The findings showed a prevalent traditional nursing management style in the study setting. Supportive strategies and education must be provided for both managers and staff nurses to develop and implement shared governance in their practice.

Measuring and Exploring Factors of Shared Leadership in the Context of Indian IT Sector

This research article explores the factors of shared leadership in IT sector in India. A reliable and a valid scale for the measurement of shared leadership (Scale for Measuring Shared Leadership, SMSL) is therefore developed as the previous researches brought to light the requirement of such scales which relate to the Indian IT sector. An attempt is made to reduce large number of variables, studied in relation to the shared leadership from various books and research journals, to a few workable factors and analyse how the factors derived explain the latent construct of shared leadership in the context of IT sector in India. The article also explores the factors of shared leadership using the factorial analysis of the data collected from teams working in the IT sector in India. It is a team level study of shared leadership in IT sector with a focus on obtaining the factors by using the factor analysis method on IBM SPSS. The various variables by which researchers have tried to explain the construct of shared leadership were collected from secondary sources which were then used to develop a questionnaire. The questionnaire was pilot tested and its reliability and validity was evaluated thereafter. Data collected was put to factor analysis through SPSS software to obtain the factors explaining the shared leadership construct in the context of the Indian IT sector. Numerous variables were reduced to few factors. With their help, these factors of the shared leadership in IT sector could be explained as a construct. The findings of this article also include explanation of the variations in the construct of shared leadership in IT sector and which factors contribute in what order to these variations.

Setting the agenda for nurse leadership in India: what is missing

Background

Current policy priorities to strengthen the nursing sector in India have focused on increasing the number of nurses in the health system. However, the nursing sector is afflicted by other, significant problems including the low status of nurses in the hierarchy of health care professionals, low salaries, and out-dated systems of professional governance, all affecting nurses’ leadership potential and ability to perform. Stronger nurse leadership has the potential to support the achievement of health system goals, especially for strengthening of primary health care, which has been recognised and addressed in several other country contexts. This research study explores the process of policy agenda-setting for nurse leadership in India, and aims to identify the structural and systemic constraints in setting the agenda for policy reforms on the issue.

Methods

Our methods included policy document review and expert interviews. We identified policy reforms proposed by different government appointed committees on issues concerning nurses’ leadership and its progress. Experts’ accounts were used to understand lack of progress in several nursing reform proposals and analysed using deductive thematic analysis for ‘legitimacy’, ‘feasibility’ and ‘support’, in line with Hall’s agenda setting model.

Results

The absence of quantifiable evidence on the nurse leadership crisis and treatment of nursing reforms as a ‘second class’ issue were found to negatively influence perceptions of the legitimacy of nurse leadership reform. Feasibility is affected by the lack of representation of nurses in key positions and the absence of a nurse-specific institution, which is seen as essential for creating visibility of the issues facing the profession, their processing and planning for policy solutions. Finally, participants noted the lack of strong support from nurses themselves for these policy reforms, which they attributed to social disempowerment, and lack of professional autonomy.

Conclusions

The study emphasises that the nursing empowerment needs institutional reforms to facilitate nurse’s distributed leadership across the health system and to enable their collective advocacy that questions the status quo and the structures that uphold it.

A One Health Evaluation of the Southern African Centre for Infectious Disease Surveillance

Rooted in the recognition that emerging infectious diseases occur at the interface of human, animal, and ecosystem health, the Southern African Centre for Infectious Disease Surveillance (SACIDS) initiative aims to promote a trans-sectoral approach to address better infectious disease risk management in five countries of the Southern African Development Community. Nine years after SACIDS’ inception, this study aimed to evaluate the program by applying a One Health (OH) evaluation framework developed by the Network for Evaluation of One Health (NEOH). The evaluation included a description of the context and the initiative, illustration of the theory of change, identification of outputs and outcomes, and assessment of the One Healthness. The latter is the sum of characteristics that defines an integrated approach and includes OH thinking, OH planning, OH working, sharing infrastructure, learning infrastructure, and systemic organization. The protocols made available by NEOH were used to develop data collection protocols and identify the study design. The framework relies on a mixed methods approach by combining a descriptive and qualitative assessment with a semi-quantitative evaluation (scoring). Data for the analysis were gathered during a document review, in group and individual interviews and in an online survey. Operational aspects (i.e., OH thinking, planning, and working) were found to be balanced overall with the highest score in the planning dimension, whereas the infrastructure (learning infrastructure, systemic organization, and sharing infrastructure) was high for the first two dimensions, but low for sharing. The OH index calculated was 0.359, and the OH ratio calculated was 1.495. The program was praised for its great innovative energy in a difficult landscape dominated by poor infrastructure and its ability to create awareness for OH and enthuse people for the concept; training of people and networking. Shortcomings were identified regarding the balance of contributions, funds and activities across member countries in the South, lack of data sharing, unequal allocation of resources, top-down management structures, and limited horizontal collaboration. Despite these challenges, SACIDS is perceived to be an effective agent in tackling infectious diseases in an integrated manner.

A Systems Approach to Evaluate One Health Initiatives

Challenges calling for integrated approaches to health, such as the One Health (OH) approach, typically arise from the intertwined spheres of humans, animals, and ecosystems constituting their environment. Initiatives addressing such wicked problems commonly consist of complex structures and dynamics. As a result of the EU COST Action (TD 1404) "Network for Evaluation of One Health" (NEOH), we propose an evaluation framework anchored in systems theory to address the intrinsic complexity of OH initiatives and regard them as subsystems of the context within which they operate. Typically, they intend to influence a system with a view to improve human, animal, and environmental health. The NEOH evaluation framework consists of four overarching elements, namely: (1) the definition of the initiative and its context, (2) the description of the theory of change with an assessment of expected and unexpected outcomes, (3) the process evaluation of operational and supporting infrastructures (the "OH-ness"), and (4) an assessment of the association(s) between the process evaluation and the outcomes produced. It relies on a mixed methods approach by combining a descriptive and qualitative assessment with a semi-quantitative scoring for the evaluation of the degree and structural balance of "OH-ness" (summarised in an OH-index and OH-ratio, respectively) and conventional metrics for different outcomes in a multi-criteria-decision-analysis. Here, we focus on the methodology for Elements (1) and (3) including ready-to-use Microsoft Excel spreadsheets for the assessment of the "OH-ness". We also provide an overview of Element (2), and refer to the NEOH handbook for further details, also regarding Element (4) (http://neoh.onehealthglobal.net). The presented approach helps researchers, practitioners, and evaluators to conceptualise and conduct evaluations of integrated approaches to health and facilitates comparison and learning across different OH activities thereby facilitating decisions on resource allocation. The application of the framework has been described in eight case studies in the same Frontiers research topic and provides first data on OH-index and OH-ratio, which is an important step towards their validation and the creation of a dataset for future benchmarking, and to demonstrate under which circumstances OH initiatives provide added value compared to disciplinary or conventional health initiatives.

On the Receiving End

This study focuses on the interpretations and experiences of change recipients, those who carry out organizational interventions initiated by others. Based on the ways nurses experienced a shared governance initiative implemented in their hospital, the authors investigated change recipients’ sensemaking about organizational change through their ascribed meanings, emotional responses, and perceptions of its impacts on them. Survey data demonstrated how nurses subjectively assessed their gains and losses from the change initiative. Participation in the initiative increased the experience of gains, as did membership in a unit where change was implemented more fully. Textual analysis of open-ended responses to the survey indicated that gains were linked with interpretations of the change initiative and pleasant feelings and that there was considerable emotional contagion within work units. Such effects are particularly likely in employee empowerment initiatives as experiences are linked to interpretation and mood among change recipients.

Analyzing barriers and facilitators to the implementation of an action plan to strengthen the midwifery professional role: a Moroccan case study

BACKGROUND

As part of a national strategy for reaching Millennium Development Goals 4 and 5 in Morocco, an action plan covering three systems (sociocultural, educational and professional) was developed to strengthen midwives' professional role in order to contribute to high quality maternity care. This study aimed to understand the implementation process by identifying the characteristics of this intervention and the dimensions of the three-systems which could act as barriers to/facilitators of the implementation process. We used a conceptual framework that builds on Hatem-Asmar's model that describes change in a health professional role; and on the Consolidated Framework for Implementation Research for our analysis.

METHODS

An embedded case study with three levels of analysis was conducted during June and July 2010. Data were collected through 11 semi-structured interviews, 20 focus groups, training session observations and documents. A purposive sample of 106 multi-stakeholders from two Moroccan regions (health professionals, academic staff, students, medical administrative officers and health programmers) and one international consultant were recruited. A thematic analysis was conducted using QDA Miner.

RESULTS

Data showed a failure to carry out the plan as intended. Seventeen barriers and seven facilitators were identified. Misalignment of the values, methods, actors and targets of the sociocultural system with the values, methods and actors of the educational and professional systems, on one hand, and with the intervention, on the other hand, were likely the greatest impediments to implementing the plan. The bureaucratic structure and lack of readiness of the sociocultural system were among the most influential barriers to: dissemination of information, involvement of key actors in the process and readiness of the educational system. The main facilitators were the values promoted related to human rights, and the national and international policies to strengthen midwifery and reduce maternal mortality. The plan was perceived as beneficial, but complex and externally driven.

CONCLUSIONS

The findings suggest that successful implementation requires redesigning the implementation strategy to adapt to the factors identified in our study. The results would be very useful to health planners seeking the expansion of such an intervention to other developing countries looking to strengthen midwives' role and to improve maternity health care services.

Exploring the relationship between governance mechanisms in healthcare and health workforce outcomes: a systematic review

BACKGROUND

The objective of this systematic review of diverse evidence was to examine the relationship between health system governance and workforce outcomes. Particular attention was paid to how governance mechanisms facilitate change in the workforce to ensure the effective use of all health providers.

METHODS

In accordance with standard systematic review procedures, the research team independently screened over 4300 abstracts found in database searches, website searches, and bibliographies. Searches were limited to 2001-2012, included only publications from Canada, the United Kingdom, the Netherlands, New Zealand, Australia, and the United States. Peer- reviewed papers and grey literature were considered. Two reviewers independently rated articles on quality and relevance and classified them into themes identified by the team. One hundred and thirteen articles that discussed both workforce and governance were retained and extracted into narrative summary tables for synthesis.

RESULTS

Six types of governance mechanisms emerged from our analysis. Shared governance, Magnet accreditation, and professional development initiatives were all associated with improved outcomes for the health workforce (e.g., decreased turnover, increased job satisfaction, increased empowerment, etc.). Implementation of quality-focused initiatives was associated with apprehension among providers, but opportunities for provider training on these initiatives increased quality and improved work attitudes. Research on reorganization of healthcare delivery suggests that changing to team-based care is accompanied by stress and concerns about role clarity, that outcomes vary for providers in private versus public organizations, and that co-operative clinics are beneficial for physicians. Funding schemes required a supplementary search to achieve adequate depth and coverage. Those findings are reported elsewhere.

CONCLUSIONS

The results of the review show that while there are governance mechanisms that consider workforce impacts, it is not to the extent one might expect given the importance of the workforce for improving patient outcomes. Furthermore, to successfully implement governance mechanisms in this domain, there are key strategies recommended to support change and achieve desired outcomes. The most important of these are: to build trust by clearly articulating the organization's goal; considering the workforce through planning, implementation, and evaluation phases; and providing strong leadership.

The effectiveness of an aged care specific leadership and management program on workforce, work environment, and care quality outcomes: design of a cluster randomised controlled trial

Background

A plethora of observational evidence exists concerning the impact of management and leadership on workforce, work environment, and care quality. Yet, no randomised controlled trial has been conducted to test the effectiveness of leadership and management interventions in aged care. An innovative aged care clinical leadership program (Clinical Leadership in Aged Care − CLiAC) was developed to improve managers’ leadership capacities to support the delivery of quality care in Australia. This paper describes the study design of the cluster randomised controlled trial testing the effectiveness of the program.

Methods

Twenty-four residential and community aged care sites were recruited as managers at each site agreed in writing to participate in the study and ensure that leaders allocated to the control arm would not be offered the intervention program. Sites undergoing major managerial or structural changes were excluded. The 24 sites were randomly allocated to receive the CLiAC program (intervention) or usual care (control), stratified by type (residential vs. community, six each for each arm). Treatment allocation was masked to assessors and staff of all participating sites. The objective is to establish the effectiveness of the CLiAC program in improving work environment, workforce retention, as well as care safety and quality, when compared to usual care. The primary outcomes are measures of work environment, care quality and safety, and staff turnover rates. Secondary outcomes include manager leadership capacity, staff absenteeism, intention to leave, stress levels, and job satisfaction. Differences between intervention and control groups will be analysed by researchers blinded to treatment allocation using linear regression of individual results adjusted for stratification and clustering by site (primary analysis), and additionally for baseline values and potential confounders (secondary analysis). Outcomes measured at the site level will be compared by cluster-level analysis. The overall costs and benefits of the program will also be assessed.

Discussion

The outcomes of the trial have the potential to inform actions to enhance leadership and management capabilities of the aged care workforce, address pressing issues about workforce shortages, and increase the quality of aged care services.

Trial registration

Australian New Zealand Clinical Trials Registry (ACTRN12611001070921)

Impact of professional nursing practice environment and psychological empowerment on nurses' work engagement: test of structural equation modelling

AIM

This study aimed to investigate the influence of professional nursing practice environment and psychological empowerment on nurses' work engagement.

BACKGROUND

Previous researchers have acknowledged the positive influence that nurse work environment and psychological empowerment have on engagement. However, less is known about the mechanisms that explain the links between them.

METHOD

A predictive, non-experimental design was used to test the model in a random sample of 300 clinical nurses from two tertiary first class hospitals of Tianjin, China. The Utrecht Work Engagement Scale, the Practice Environment Scale of the Nursing Work Index and the Psychological Empowerment Scale were used to measure the study variables.

RESULT

Structural equation modelling revealed a good fit of the model to the data based on various fit indices (P = 0.371, χ(2) /df = 1.056, goodness of fit index = 0.967), which indicated that both professional practice environment and psychological empowerment could positively influence work engagement directly, and professional practice environment could also indirectly influence work engagement through the mediation of psychological empowerment.

CONCLUSION

The study hypotheses were supported. Psychological empowerment was found to mediate the relationship between practice environments and work engagement.

IMPLICATIONS FOR NURSING MANAGEMENT

Administrators should provide a professional nursing practice environment and empower nurses psychologically to increase nurse engagement.

Transforming work place relationships through shared decision making

AIM

Using Donabedian's Structure-Process-Outcomes (SPO) paradigm, this study explored the SPO linkages related to nurse-nurse leader shared decision making around workload issues, such as safe staffing assignments.

BACKGROUND

Shared decision making represents nurses' control over practice, which is associated with positive nurse outcomes, such as job satisfaction. This study is based upon four project sites where nurse-led project teams addressed workload issues.

METHODS

Participatory action research was used, with the authors acting as participant observers. Four sites were case ordered and analysed: least successful to most successful outcomes. Cross-case matrices were constructed to identify SPO linkages. Data included observation field notes, interviews and focus groups.

RESULTS

Operations leaders with formal access to empowerment structures, such as information and resources, were the critical link to successful outcomes. Sites with conflict that blocked team-operations leader relationships were unable to engage in effective, sustainable decision making.

CONCLUSIONS

Effective work relationships among teams consisting of staff and front-line leaders contributed to successful outcomes, but team-operations leader relationships made the biggest difference.

IMPLICATIONS FOR NURSING MANAGEMENT

Formal access to power through leadership is critical for building and sustaining processes that promote and sustain nurses' control over practice.

Nurses' views of shared leadership in ICU: a case study

New management models develop; one of them is shared leadership where two nurse managers share tasks and responsibility for a unit. The overall aim of this study was to describe the view of the staff about shared leadership at an ICU in Sweden and to study if there were any differences in perceptions between staff groups. This unit had changed the management organisation from single leadership (one nurse manager) to shared leadership (two nurse managers). Sixty-four (79%) registered nurses and assistant nurses responded to a 72 item questionnaire measuring social and organisational factors at work, especially leadership and shared leadership. The results showed that staff reported positive views in relation to the dimensions 'Organisational culture', 'Social interactions', 'Work satisfaction', 'Leadership', 'Shared leadership' and 'Work motives'. Registered nurses reported more positive views than assistant nurses in relation to the dimensions: 'Organisational culture', 'Social interactions', 'Work satisfaction' and 'Leadership'. Further, females had more positive views than males on the dimension 'Social interactions'. Staff described that shared leadership positively influenced the work in terms of confidence. In conclusion, staff reported positive views of work and the model shared leadership in the investigated ICU. One implication is that nurse managers have to be conscious of different health professionals in the unit and it is important to offer a good working environment for all staff. However, more research is needed within the area of shared leadership. A future research project could be to add a qualitative research question about how work and shared leadership affects different health professionals in the day to day practice both at the managerial as well as the team level to improve health care.

Factors associated with success and breakdown of shared governance

Shared governance (SG), a process for empowering nurses in practice settings, has been widely used for decades. However, despite enthusiasm for the concept, the process is not always successful or falters after successful initiation. To assist nursing leaders trying to implement or maintain SG processes, the author summarizes literature on both human and structural factors that contribute to the success or breakdown of SG practice models. Barriers to implementation and strategies to support implementation, as well as enculturation of SG, are discussed.

Policy options to improve leadership of middle managers in the Australian residential aged care setting: a narrative synthesis

Background

The prevalence of both chronic diseases and multi-morbidity increases with longer life spans. As Australia's population ages, the aged care sector is under increasing pressure to ensure that quality aged care is available. Key to responding to this pressure is leadership and management capability within the aged care workforce. A systematic literature review was conducted to inform the policy development necessary for the enhancement of clinical and managerial leadership skills of middle managers within residential aged care.

Methods

Using scientific journal databases, hand searching of specialist journals, Google, snowballing and suggestions from experts, 4,484 papers were found. After a seven-tiered culling process, we conducted a detailed review (narrative synthesis) of 153 papers relevant to leadership and management development in aged care, incorporating expert and key stakeholder consultations.

Results

• Positive staff experiences of a manager's leadership are critical to ensure job satisfaction and workforce retention, the provision of quality care and the well-being of care recipients, and potentially a reduction of associated costs.

• The essential attributes of good leadership for aged care middle management are a hands-on accessibility and professional expertise in nurturing respect, recognition and team building, along with effective communication and flexibility. However, successful leadership and management outcomes depend on coherent and good organisational leadership (structural and psychological empowerment).

• There is inadequate preparation for middle management leadership roles in the aged care sector and a lack of clear guidelines and key performance indicators to assess leadership and management skills.

• Theory development in aged care leadership and management research is limited. A few effective generic clinical leadership programs targeting both clinical and managerial leaders exist. However, little is known regarding how appropriate and effective they are for the aged care sector.

Conclusions

There is an urgent need for a national strategy that promotes a common approach to aged care leadership and management development, one that is sector-appropriate and congruent with the philosophy of person-centred care now predominant in the sector. The onus is on aged care industries as a whole and various levels of Government to make a concerted effort to establish relevant regulation, legislation and funding.

OPTIGOV - A new methodology for evaluating Clinical Governance implementation by health providers

Background

The aim of Clinical Governance (CG) is to the pursuit of quality in health care through the integration of all the activities impacting on the patient into a single strategy.

OPTIGOV (Optimizing Health Care Governance) is a methodology for the assessment of the level of implementation of CG within healthcare organizations. The aim of this paper is to explain the process underlying the development of OPTIGOV, and describe its characteristics and steps.

Methods

OPTIGOV was developed in 2006 by the Institute of Hygiene of the Catholic University of the Sacred Heart and Eurogroup Consulting Alliance. The main steps of the process were: choice of areas for analysis and questionnaire development, based on a review of scientific literature; assignment of scores and weights to individual questions and areas; implementation of a software interfaceable with Microsoft Office.

Results

OPTIGOV consists of: a) a hospital audit with a structured approach; b) development of an improvement operational plan. A questionnaire divided into 13 areas of analysis is used. For each area there is a form with a variable number of questions and "closed" answers. A score is assigned to each answer, area of analysis, healthcare department and unit. The single scores can be gathered for the organization as a whole.

The software application allows for collation of data, calculation of scores and development of benchmarks to allow comparisons between healthcare organizations. Implementation consists of three stages: the preparation phase includes a kick off meeting, selection of interviewees and development of a survey plan. The registration phase includes hospital audits, reviewing of hospital documentation, data collection and score processing. Lastly, results are processed, inserted into a final report, and discussed in a meeting with the Hospital Board and in a final workshop.

Conclusions

The OPTIGOV methodology for the evaluation of CG implementation was developed with an evidence-based approach. The ongoing adoption of OPTIGOV in several projects will put to the test its potential to realistically represent the organization status, pinpoint criticalities and transferable best practices, provide a plan for improvement, and contribute to triggering changes and pursuit of quality in health care.

Development of a reliable and valid organization-specific professional practice assessment tool

PURPOSE

This article describes a study to devise an organization-specific professional practice model (PPM) assessment that reflects actual unit involvement. A secondary study goal is the development of a unit-based index that can be used to conduct comparative analyses in an efficient way.

DESIGN

Each of the 5 elements of the organization's PPM was represented by 1 or more items on an author-developed instrument. The tool was structured so that item scores could be summed to achieve a single subscale for each PPM element and further aggregated into a total score.

METHODS

The instrument was administered to a 40% random sample of all regularly scheduled, full- and part-time registered nurses in an academic, community Magnet hospital in 2003 and 2005. Descriptive statistics were calculated for items, subscales, and summary scores for each patient care unit and overall. A weighted, unit-based index was developed to reflect each unit's score on a scale of 100.

FINDINGS

The 2003 assessment response rate was 51% (n = 200); the 2005 response rate was 48% (n = 193). Subscale scores and a total PPM score were calculated by summing the values of each individual item. Submissions enabled calculations of total scores by unit, mean scores by item, and the development of a unit-specific PPM index of performance.

CONCLUSIONS

Beyond shared principles of empowerment, the specifics of each organization's PPM may differ in those key components of care delivery nurses are empowered to effect. Thus, fidelity to the organization-specific PPM is not well tested with generic decisional-involvement instruments. An organization-specific assessment such as this one can provide evidence of not only organizational PPM fidelity but a quantitative method to ensure that staff nurse decisional involvement is continuously evolving to an ever higher state.

Process evaluation of the Community Support Connections merger

Community Support Connections (CSC) is the result of the merger of four private not-for-profit community health care agencies. The purpose of this research project was to evaluate the progress of CSC toward its stated goal: improvement of coordination and accessibility of health services. As of this writing, more than one year into the merger, managers, staff and volunteers believe that the goals of serving more clients more completely through case management are being achieved.

Effects of organizational change on work-related empowerment, employee satisfaction, and motivation

This article reports the results of a longitudinal quantitative study on nurses' views on factors promoting and impeding empowerment and examines the relationship between work-related empowerment and background variables in one hospital. Data were collected using a self-administered questionnaire and analyzed statistically. Nurses gave lowest assessments of promoting factors on the second measurement occasion, a time when the organization was going through major changes. Both job satisfaction and motivation showed a positive relationship with factors promoting empowerment. Organizational changes have a direct effect on the work environment in terms of empowerment and job satisfaction. To cope successfully with changes, special attention must be paid to personnel management. It seems that factors promoting and impeding empowerment can be used to measure effects of organizational changes as well.

Presence and availability: staff conceptions of nursing leadership on an intensive care unit

A demand for high quality care has drawn attention to leadership issues. The nurse managing role has changed over the years and become more complex with a high burden of work. Few studies describe the perspective of 'those being lead'. The aim of this study was to describe staff conceptions about nursing leadership on an intensive care unit. Ten members of staff were interviewed and analysed according to a phenomenographical approach, focusing variations in how informants experience nursing leadership and make sense of the world around them. The findings show that nursing leadership was considered to be 'being present and available in daily work', 'supporting everyday practice', 'facilitating professional acknowledgement' and to 'improve care both as individuals and as a team'. Transformational leadership seemed to be suitable to meet the staff perspective. In such leadership communicative skills is a core to work with strong professionals by being present and available.

Development of a Unit-Based Practice Committee: A Form of Shared Governance

Nursing leaders at one facility challenged staff nurses in the postanesthesia care unit (PACU) to implement a modified process of shared governance, a model that allows staff nurses to influence their practice. As a result of this initiative, PACU nurses were able to collaborate with other perioperative staff members, ultimately increasing patient safety. Successes included increased staff nurse participation in educational projects; increased interdisciplinary collaboration; personal and professional development for the nurses involved; and recognition from a highly esteemed, national organization.

Organizational change and work-related empowerment

AIM

This study describes the views of multidisciplinary teams on work-related empowerment in a transitional organization.

METHODS

The data were collected between September 2003 and January 2004 (n=115) and one year later (n=112) using a self-administered questionnaire consisting of verbal and behavioural items, empowerment outcomes, and factors promoting and impeding empowerment. The target population consisted of all members working in multidisciplinary teams at the Rheumatism Foundation Hospital in Finland. The response rate was 58% at both data collections. The data were analysed statistically using SPSS software.

RESULTS

The multidisciplinary teams rated their work empowerment quite highly. The number of empowerment promoting factors was lowest for the category of future orientedness, consisting of continuity of work, opportunities for advancement, and access to information. The number of impeding factors was also highest for the same category of future orientedness, consisting here of organizational bureaucracy and hierarchy, authoritarian leadership, poor access to information, and short working periods.

CONCLUSIONS

It is important not to underestimate the impacts of organizational changes: they have a direct effect on the work environment and may contribute to higher rates of dissatisfaction, burnout and absenteeism among health care workers.

Shared Governance

The shared governance literature contains numerous examples of how to design and implement nursing shared governance models. However, there is a major gap between design/implementation and a change in culture. A change in nursing culture will support viability of this governance model. The authors detail the steps taken by a shared governance transition team to help a large nursing organization make changes in governance process and perception as well as to incorporate a maintenance plan.

Good governance and sustainability: a case study from Pakistan

OBJECTIVE

On the basis of a case study in Pakistan, the paper argues that good governance, characterized by transparency, accountability and meaningful community participation, plays a critical role in the sustainability of donor-funded health systems projects in the public health sector.

METHODS

The Family Health Project (FHP) (1992-1999), funded by the World Bank, has been used as a case study. Critical analysis of secondary data mainly obtained from the Department of Health (DoH) in the province of Sindh in Pakistan is the major tool used for the study. Data from other sources including the World Bank have also been used.

RESULTS

The analysis reveals that the existing health care system could not fully absorb and sustain major "sociopolitical" thrusts of the project, meaningful community participation and "democratic" decision-making processes being the most important ones. The hierarchical structure and management process made it difficult to produce a sense of ownership of the project among all managers and the rank and file staff. The Provincial Health Development Center (PHDC) and District Health Development Centers (DHDCs) established by the FHP did not receive adequate financial and political support from DoH and the Ministry of Health to have much control of the project at the local level. Consequently, these Centers largely failed to institutionalize a continuing training program for district level health officials/professionals. Due to lack of political support, the District Health Management Teams (DHMTs) could not be institutionalized. Community participation in the DHMTs was symbolic rather than forceful. Improved coordination among all stakeholders, more stable and competent leadership, more meaningful community participation, greater devolution of project management to the district level, and better management of resources would have resulted in more effective and efficient implementation of the project. Based on these findings, the paper introduces a Sustainable Management Approach (SMA) as a tool that can be used to ensure the sustainability of health systems projects, particularly those funded by international organizations in developing countries.

CONCLUSIONS

Good governance and a conducive organizational culture are important prerequisites for incorporating any new project within an existing system. This includes prior consensus building among all stakeholders, a meaningful and inclusive participatory planning, implementation and evaluation process involving communities, political commitment, and the identification and use of appropriate leadership for project management.

Education leadership in the clinical health care setting: a framework for nursing education development

This paper describes how a new framework for clinical nursing education was introduced at Counties Manukau District Health Board (CMDHB), New Zealand. The project was initiated in response to the significant legislative and post registration nursing education changes within New Zealand. The journey of change has been a significant undertaking, and has required clear management, strong leadership, perseverance and understanding of the organisation's culture. The approach taken to managing the change had four stages, and reflects various change management models. The first stage, the identification process, identified the impetus for change. Creating the vision is the second stage and identified what the change would look like within the organisation. To ensure success and to guide the process of change a realistic and sustainable vision was developed. Implementing the vision was the third stage, and discusses the communication and pilot phase of implementing the nursing education framework. Stage four, embedding the vision, explores the process and experiences of changing an education culture and embedding the vision into an organisation. The paper concludes by discussing the importance of implementing robust, consistent, strategic and collaborative processes--that reflect and evaluate best educational nursing practice.

Perceptions, knowledge, and commitment of clinical staff to shared governance

The perceptions, knowledge, and commitment of clinical staff to shared governance were explored in a nonexperimental, survey research design, wherein preimplementation responses were compared to postimplementation responses. Using a nonprobability sampling method, all clinical staff members had the opportunity to respond to the Shared Governance Survey at the preimplementation and the 1-year postimplementation period. Thirty-eight clinical areas, including inpatient and outpatient areas, were included in the study. Both surveys contained a short demographic section and the Shared Governance Survey adapted from Minors et al. Results showed a decrease in perception and knowledge of shared governance between the 2 survey periods. This pattern was attributed to the idealism of shared governance in the preimplementation period compared to the reality of implementing shared governance. Interestingly, commitment to shared governance increased during this same time. When the sample was divided into groups, participants in shared governance had significantly higher scores on perception and knowledge of shared governance than did nonparticipants. Overall, participants and nonparticipants were committed to shared governance. The results of the survey indicated that clinical staff members recognized shared governance as a process, not a project, and that it takes time to share responsibility, accountability, and authority for nursing practice.

Commitment of project participants to developing health care services based on the internet technology

BACKGROUND

When developing Information and Communication Technology (ICT), such as services for the decision-making process, skilled health care professionals with their comprehensive knowledge of patients/clients are essential contributors to the project. Careful evaluation is needed to assess the effectiveness of project management as well as to analyze the commitment of the personnel to goal attainment.

OBJECTIVE

In the course of the development of integrated maternity care services, the commitment of project participants (n=48) was evaluated. What factors enhanced or impaired their commitment to the project work?

METHODS

Questionnaire (n=80, response rate 60%) with quantitative analysis as well as open-ended questions with qualitative content analysis.

RESULTS

Positive commitment was related to a confidential and open atmosphere during the project. The utilization of personal skills and experience was appreciated. Differences in the working principles and cultures between the participating organizations complicated fluent collaboration. To encourage commitment, a lot of attention should be paid to internal communication as well as the effective realization of project tasks.

CONCLUSION

The strength of the project was the highly innovative and confidential atmosphere. The well-established project goals, the highly inspired project team, and the effective co-operation between the project manager and the core group helped to deepen overall commitment in the project.