The original Magnet(R) hospital study, conducted by a team of American Academy of Nursing researchers in the 1980s, referred to shared decision making as "participatory management" and "active involvement of staff in planning and decision making."1(p44) The team found that nurses who were able to participate in decisions at the unit, department, or hospital level showed increased engagement in their practice. Decisions might include staffing, policies and procedures, professional development, resources, and even innovation and research. Over time, the term "participatory management" has been replaced by shared governance, unit councils, and professional governance. Today, the Magnet Recognition Program(R) defines shared decision making as "a dynamic partnership between leadership, nurses, and other health care professionals that promotes collaboration, facilitates deliberation and decision making, and fosters accountability for improving patient outcomes, quality, and enhancing work life."2(p202)
Evidence continues to support the value of shared decision making in healthcare settings, and the concept is foundational to Magnet-designated organizations. First-time applicants, as well as organizations seeking redesignation, must provide ample evidence of how shared decision making is embedded in their culture. The 2023 Magnet Application Manual requires organizations to use shared governance as "a model in which nurses are formally organized to make decisions about clinical practice standards, quality improvement, staff and professional development, and research."2(p38) In the Organizational Overview, OO5 requires organizations to provide a description of nursing's structural and operational relationship within the organization's shared decision making structure.2(p19) The exemplary professional practice (EP) component2 strengthens the concept of shared decision making to include accountability and interprofessional collaboration: "Nurses create patient care delivery systems that delineate the nurses' shared authority and accountability for evidence-based nursing practice, clinical decision making and outcomes, performance improvement initiatives, and staffing and scheduling processes."(p54) In addition, the Commission on Magnet added a new source of evidence, EP2, in which organizations must provide an example of clinical nurses using shared decision making to change the nurse practice environment.2
Elevating Nurse Engagement and Patient Care
As noted previously, a shared governance culture involves staff nurses in decision making in clinical settings. Research shows that nurses who can influence decisions feel more engaged. Higher engagement leads to better patient outcomes. Nurmeksela et al3 report that shared decision making encourages staff to express issues and concerns regarding professional practice, service quality, and competency in practice. In today's volatile environment, shared decision making enhances authentic partnerships between nurses and nurse leaders, which adds value. Significantly, the authors found that nurse managers anticipate a continued shift from hierarchical leadership to shared governance with nursing staff playing a more active role.3
In 2017, Clavelle et al4 found that the necessity for shared decision making has strengthened over time. What was initially shared governance has matured to a concept of professional governance, to include attributes of accountability, professional obligation, collateral relationships, and effective decision making. The authors report that as the healthcare environment grows more complex, so does the need for the full contribution and commitment of nurses as engaged and aligned members of the team. Current systems demand stronger partnerships and collaborative foundations to deliver integrated, value-based services.4 These research findings resonate with previous studies that found a strong link between shared governance and increased nurse empowerment, self-management, engagement, and satisfaction. They reflect the need for nurse managers to promote and recognize staff participation in a shared governance structure.5
Shared Decision Making and the COVID Crisis
Evidence continues to mount that organizations with strong shared governance cultures were able to quickly adjust during the early days of the COVID-19 pandemic, especially when it came to dismantling chain of command and delegating decision making to bedside nurses. These organizations often had better patient outcomes. However, some administrators used the COVID crisis to push shared governance aside, ignoring the positive association with professional, patient, and organizational outcomes. Hess et al6 believe the sustainment of shared governance in a crisis depended on whether or not the organization had a well-enculturated model.
Organizations that foster shared decision making that support employee engagement outperform their counterparts in job satisfaction, retention, and financial performance.7 In a competitive environment of staffing challenges, hospitals have a vested interest in promoting a culture of engagement among nurses.
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