Clinical governance and infrastructure: Nursing retention toolkit
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- Goal statement
- Initiative – Structured participatory governance: Ensure nursing leadership is present in governance and has meaningful authority
- Initiative – Nursing shared governance: Create nursing structures to connect nurses and involve them in decision making
- Initiative – Nurse-led models of care, initiatives and practice standards: Ensure nursing care provision is defined by nurses and supported by practice standards grounded in nursing knowledge.
Goal statement
Ensure that supportive clinical governance and infrastructure is in place to ensure that nurses have a core role in decision-making and are at the forefront of driving the development of a sustainable health system.
Initiative – Structured participatory governance: Ensure nursing leadership is present in governance and has meaningful authority.
Intended outcome
- Having the voice of point-of-care nurses in decision-making to meet the needs of nurses.
- More efficient decision-making and meaningful participation by allowing time for different point-of-care staff to participate in governance.
Description
This initiative aims to ensure nursing leadership is present across all organizational governance structures, including at the executive table and board, and includes their ability to lead clinical care design, delivery, and evaluation. Participatory governance facilitates executive leadership being informed and accountable to the nursing workforce.
Key activities include:
- Defining the structural elements: A Chief Nurse Executive should participate at the C-suite level, reporting to the CEO and maintaining a seat on the Quality Committee of the Board. Shared decision-making structures should be developed, with clear decision-making authorities. Roles for Advanced Practice Nurses to participate at leadership levels should be well defined.
- Establishing a Nursing Advisory Committee: Ensure that nursing has a voice at the organizational level through the development of a Nursing Advisory Committee, with various levels of nurses represented and participating. This committee should report to the Chief Nursing Executive, who would then bring issues to the Board.
Planning considerations include:
- Long-term organizational commitment: Sustainability and longevity of the structural elements can be supported by updating organizational structure-related documents and organizational policies. These activities can facilitate structured participatory governance that is incorporated into the fabric of the organization. Structural elements, including the governance responsibilities of Chief Nursing Officers (CNOs) in job descriptions, and developing nurse or administration dyads (e.g., CNOs and Chief Operating Officers (COOs)) may support sustained results.
- Creating feedback loops: Develop processes to continuously monitor and evaluate whether elements of structured participatory governance (i.e., specific roles, committees, decision-making structures) exist and are functioning as intended, and whether input from nursing leaders and structures such as Nursing Advisory Committees is actively implemented and used. For example, integration of nurse-initiated protocols that aim to better meet the needs of scope of practice could be audited. Employing methods such as Plan-Do-Study-Act (PDSA), which is a four-stage problem-solving model, can support the use of evaluation mechanisms.
- Preserving the distinct role of nursing: Organizations need to recognize the need for inclusive leadership structures that enable interprofessional practices and encompass all health care and social services staff while preserving the distinct role of nursing to ensure effective management of the nursing workforce. CNO roles at organizations should be protected roles that enable the CNO to drive a strategic vision that meets the needs of nurses. These roles, where possible, should not be combined with other operational roles and responsibilities.
Target nursing population
All (Student, New Grad, Mid-Career, Late-Career, Managers and Faculty, etc.)
Stakeholder involvement and role of nurses
- Responsible: Boards of directors, Ministry of Health and CEOs, who are able to influence significant structural change.
- Accountable, consulted, informed: Those involved in direct care, which reinforces cascading governance structures.
- Note that CNOs currently have no operational authority in certain provinces. Ensure role clarity to prevent confusion among nurses. A shift to structured participatory governance may help address this.
Reference resources and examples (See appendix for links)
- RNAO Chief Nursing Executive Role Framework: Provides an overview of the Chief Executive role and responsibilities such as participating in a voting role on Quality committees and ensuring forums exist within organizations for nursing decision-making.
- The Ottawa Hospital Nursing Unit Councils: Forums for all nurses to participate in discussion and decision-making related to professional practice and patient care on a unit level.
- The Ottawa Hospital Corporate Nursing Clinical Practice Committee: A forum for clinical nurses representing 60-70 units across the organization to participate in discussion and decision-making that impacts nursing practice.
- Nursing and Allied Health Advisory Council at Island Health, British Columbia: A nurse-led, multidisciplinary Council aligned to the Chief Nurse Executive, directly advising senior executive, leaders, operational care areas, and beyond in policy, direction, strategy, and implementation.
- Saskatchewan Nursing Leadership Network (SNLN): This network consists of provincial nursing regulatory bodies, health authorities, nursing associations, educational institutions, nursing unions, nursing students and government representation. The network aims to support the nursing workforce in Saskatchewan through leadership, collaboration, information sharing and innovation and has defined Terms of Reference for governance.
Initiative – Nursing shared governance: Create nursing structures to connect nurses and involve them in decision making.
Intended outcome
- Solutions are not being re-worked: they are designed with delivery in mind.
- Enablement of varied tasks (e.g., research, quality improvement), as a result of a formal structure with protected time. This also creates more joy in work and may improve retention.
- Greater organizational awareness, efficiency, fiscal responsibility and improved patient outcomes as a result of shared decision-making structures that enable real-time decision-making.
Description
Nursing shared governance is about nurses being involved in decision making. This initiative is about putting nursing shared governance in place. It is centered on developing or refining formal nursing structures to enable nursing practices that connect nurses caring for patients to nurse leaders, nurse educators, and nurse-led research within the organization.
This involves:
- Removing hierarchy and reducing top-down approaches. Decisions need to start at the point-of-care, rather than in a way that applies downward pressure. There is a need for a meaningful voice that impacts decisions, rather than performative inclusion. Nurses should be empowered to initiate the decision-making process as needed.
- Creating a culture of psychological safety to broaden perspectives and allow nurses to feel comfortable bringing opinions to the table.
- Embedding nurse scientists, researchers, and educators, within improvement processes. Specifically, having embedded quality leaders – someone who has worked in the area and works in a team on a long-term basis. This results in better patient outcomes.
- Specific roles for quality improvement in a nursing workplace and unit, or point-of-care representation from all relevant nursing departments in quality improvement processes and initiatives.
- Indigenous perspectives must also be considered in nursing governance to include indigenous ways of knowing in order to improve access to high-quality, culturally relevant health services.
- Intentionality is needed in decision-making, rather than just data collection. A safe space to share ideas is an enabler to ensuring that decision-making is informed by point-of-care nurses' perspectives.
Planning considerations include:
- Participatory governance structures and resources: Creating shared participatory governance structures (detailed in initiative "Structured Participatory Governance") that enable nurse-led decision-making. Governance should include a framework that allows participation of all staff through communication channels. Nurses need to be supported to participate in governance structures through dedicated resources (e.g., communications plan). Governance structures may include a multi-disciplinary and pan-organizational steering group or council with meaningful decision-making authority.
- Empowering nurses to get involved in governance: Encourage nurses to participate in governance through training, and improve communication about opportunities to get involved.
- Embracing a dynamic journey to achieving nursing shared governance: Establishing and refining nursing shared governance is typically a dynamic process. Organizational leadership teams need to develop a tolerance for failure and be willing to test and try different approaches.
- Monitoring efficacy: Existing organizational mechanisms, such as healthcare accreditation surveys, can be leveraged and adjusted to gather feedback from staff annually.
Target nursing population
All (Student, New Grad, Mid-Career, Late-Career, Managers and Faculty, etc.)
Stakeholder involvement and role of nurses
- Responsible: Chief Nursing Officer (if possible), Board of Directors, Unit-level leadership (clinical nurse managers and managers to ensure participation).
- Accountable: Current structures for governance.
- Consulted and informed: Advanced Practice Nurses, point-of-care nurses, clinical nurse educators – (unit or workplace setting specific), union leaders, Canadian communities of practices that can help advance this initiative.
Reference resources and examples (See appendix for links)
- Le Secrétariat international des infirmières et infirmiers de l'espace francophone (SIDIIEF): Community of practice with French-speaking clinicians and nurses to share knowledge.
- Health Standards Organization (HSO) Governance Standards: HSO's governance standards include guidance on how to set up effective approaches to collaboration to make shared clinical decisions at the direct-care level. HSO's Clinical Governance Standards are forthcoming.
- Health PEI Provincial Nursing Leadership Committee (PNLC): provides strategic and operational direction and leadership to nursing and nursing services within Health PEI. The goal of the PNLC is to standardize and advance the professional practice of nursing in all practice contexts to enable quality nursing services to be delivered to the residents of Prince Edward Island.
- Alberta Health Services (AHS) CoACT Collaborative Care: AHS has developed a framework for collaborative care and delivers an introductory course for Unit Leads, including nursing leaders, to support their involvement in implementing and sustaining collaborative care and quality improvement in their practice environments.
- Process and Quality Improvement (PQI) Nurse position at the Royal Alexandra Hospital (RAH) Emergency Department: The PQI nurse facilitates the development and implementation of projects to improve care and experience in the department for patients and staff alike and reports to the Patient Care Manager.
Initiative – Nurse-led models of care, initiatives and practice standards: Ensure nursing care provision is defined by nurses and supported by practice standards grounded in nursing knowledge.
Intended outcome
- By enabling nurses to operate at full capacity and full scope in areas where there is a need may increase feelings of belonging and allow nurses to stay in their organization or community while still gaining career growth opportunities.
- Nurses feel respected and recognized for clinical skills by having a meaningful seat at the table.
- Jurisdictional consistency on nursing models and parity of opportunities.
- Decreased moral injury given nurse-led models are enacted in a way that respects nurses' clinical skills and voices.
Description
This initiative is focused on ensuring that the care that nurses provide is defined by nurses and supported by practice standards grounded in nursing knowledge, and formulated, documented, implemented, evaluated, and refreshed by nursing practice leadership structures. It is critical that nursing staff are able to adjust models of care as patient composition shifts. This change will have a significant impact in the long term but requires patience in the short term.
This involves:
- Nurses having a voice at decision-making tables to design care and influence how care is structured: Making it clear to partners that nurses are experts in their field, are at the center of patient needs, and that they must be involved in the design of models of care.
- Incorporating research from point-of-care nurses in designing action plans, roadmaps and policies (e.g., Staffing Issues Working Group): Ensuring that knowledge translation and actions actually benefit point-of-care nurses.
- Empowering nurse leadership: Refining and strengthening nurse leadership structures, if needed, to ensure that nurses have a significant role in defining care models and practice standards and decision-making processes. In addition, providing nurse leaders with ongoing educational support and access to continuous learning (e.g., new models of care).
Planning considerations include:
- Resources for innovation: Dedicated time, physical space, and funding are required to support nursing innovation.
- Facilitate knowledge translation: Develop mechanisms to translate research and insights from point-of-care nurses into actionable plans and policies, ensuring that nursing knowledge informs care delivery and practice standards.
- Regular feedback mechanisms: Implement regular feedback loops (e.g., surveys, dedicated time at team meetings) involving point-of-care nurses, nurse leaders, and other stakeholders to assess the effectiveness of nurse-led models of care and practice standards in meeting patient needs.
- Outcome metrics: Establish key outcome metrics, such as patient satisfaction scores, care outcomes, and retention outcomes to measure the impact of nurse-led care initiatives.
- Employer policy: Employer policy is a key enabler for nurse practice advisors and experts to participate in the development of nursing standards and innovation.
Target nursing population
All (Student, New Grad, Mid-Career, Late-Career, Managers and Faculty, etc.): This initiative will create a shift in culture enabling full scope and capabilities, affecting all areas of nursing.
Stakeholder involvement and role of nurses
- Responsible and accountable: All staff ranging from point-of-care to Senior Leadership teams, in particular nurse executives or leaders, with a focus on shifting power to the voice of direct care in decision-making.
- Consulted: Educators, regulators employer groups, and nurses specifically with novice experience.
- Informed: Nursing faculty should be involved, as they help create change at the baseline, school level to push forward meaningful long-term culture shifts.
Reference resources and examples (See appendix for links)
- Winnipeg Regional Health Authority Professional Committee: Comprised of roles such as allied health and nursing leadership councils, medical advisory committee, and long-term care representatives to advise the local board of directors on policy issues related to interprofessional clinical practice.
- Leadership Exchange / Leadership Network: Bring together nurse leaders and aspiring nurse leaders for networking and learning opportunities (e.g., Association of Regulated Nurses Manitoba).
- Nursing Innovation Labs: Dedicated time and space for nurses to collaborate on innovative ideas and projects (e.g., UBC Nursing IDEA Lab, Duke University School of Nursing Health Innovation Lab).
- Island Health Innovation Lab: This innovation lab was established within a health authority with the explicit intention of bringing innovation as close to care providers and patients as possible. It has grown to include mentorships for innovation activities in other health authorities and provinces. The innovation lab's annual "Code Hack" event puts 100 hackers into a hospital environment for a design sprint solving crowdsourced problems.
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