Transforming Nursing Through Shared Governance

Shared governance is revolutionizing nursing practice at Advent Health Sebring. In this interview, Tonya Clark, Assistant Nurse Manager, and Jamie Cohen, Director of Critical Care, share how this collaborative model has empowered nurses across various units, from ICU to step-down care. By fostering mentorship, improving communication, and addressing challenges like staff development and resource gaps, their team has created a more cohesive and supportive environment for both staff and patients. Read on to learn how shared governance is shaping the future of nursing and how you can help implement it in your place of work. 

Insights on Shared Governance in Nursing

allnurses: To start with your name and the organization that you work with. 

Tonya: My name is Tonya Clark, and I'm assistant nurse manager in the ICU in Sebring, Florida. 

Jamie: My name is Jamie Cohen. I'm the director of critical care over ICU at Advent Health Sebring.

allnurses: All right, first hop into it. What led you guys to be critical care, ICU nurses versus the other specialties?

Tonya: My mother was an ER nurse, and so I became an ICU nurse in rebellion. ER and ICU nurses are opposite of each other, because you only take two patients as a rule in ICU. I've always done, ICU, it's been 43 years now. I've never wanted to do anything else. 

allnurses: That's great.

Jamie: I actually didn't know what I wanted to do when I was going through nursing school, but I was able to do a practicum in ICU, and then I was lucky enough to have the opportunity to go into a Nurse Residency Program at a trauma center in Hollywood, Florida, and got selected to do a six-month long program in the Surgical Neuro Trauma ICU. 

allnurses: That had to be interesting.

Jamie: It was intense, but it was great. I learned a lot, and it really developed my love for critical care and just the whole care aspect of nursing.

allnurses: Sure, you've seen a lot. I follow a guy on Instagram, Nurse Mendoza, who I think is in Florida too.
Jamie: Yeah.

allnurses: He's got some interesting posts for sure, the first couple times I was like woah and then I kind of got used to it and was like, okay, this isn't as bad as what I first thought.

Jamie: So that's where it all started.

Tonya: Seen a lot of changes over the years. 

Jamie: Yes it has changed quite a bit, so true. 

allnurses: So can you walk me through the process of implementing the unit based shared governance for your ICU?

Tonya:

Quote

It's an opportunity to give the nurses a chance to see changes, develop in the unit, and be responsible for implementing things that they want to do to improve — concepts and practices. 

One of the things that came to our attention was that the nurses on the floor didn't feel comfortable with the emergency situations and how to deal with them. That was one of the first things that we did, is decide that we wanted to do education. So people volunteered each shift to go to the floor and get nurses together to go over the crash cart, let them feel things, play with things, and become familiar with them. 

From there, we just started developing it and coming up with different ideas and implementing them. We did the honor walk for people who did organ donations. We developed a whole system for that and saw it through. 

We're now in the process of trying to get shared governance in each of the other units in the hospital and helping them. The first thing that you do is vote for who you want to be Chairperson and co-chair and secretary, and then go from there. 

allnurses: Can you talk a little bit about how shared governance has improved communication among the nurses and the leadership?

Tonya: Leadership is involved, but they're not. We go to them and say, "this is what we have discussed, and we would like to do. How can you help us with this?” 

When we wanted to improve things in the unit, one of the things that the nurses said was that they didn't feel comfortable with the steps that you went through; that they didn't know them real well. And the EKG strips—they didn't know all of them—they wanted reference material. So I got together a package, and then we took it to the managers, and they approved it. They bought a set for each crash cart. So, we need their money. We also need their support, and they have helped us with that greatly.

Jamie: I think besides the OR, we're the only other unit currently that has a unit based shared governance. And you know, our unit is unique, it's a 20-bed unit, but it's divided so we have a 12 bed ICU, and we have a 16 bed ICU step-down or PCU level. 

With that comes a lot of challenges, because even though all 28 beds are cared for by ICU level nurses, trying to figure out a way to incorporate learning how to be an ICU nurse, which is different with a 1:2 ratio, and also being a PCU nurse, or a step-down nurse at a 1:4. Time management is different. The way you approach your day is different. The different type of patients you get, it's different. And we rotate, so that's tough. 

Especially where we are in our location, after COVID, we had a really hard time. It's hard to hire into our community now, just based on our location, we're not in a big city, so we don't get a lot of experienced nurses coming in. After COVID, we were left with about 24 open positions, which added to the difficulties we already faced. We had to get creative with hiring, so we went the route of using nurse residents. We hired a big cohort of nurse residents and worked on growing them, allowing them to become ICU nurses—like I had the opportunity to do—and directly out of school to teach them how to be ICU nurses, that's tough. Especially since they were in nursing school during COVID, they didn't get as much hands on, it was more simulation.

With that, our staffing mix became heavier on the novice nurse side, which comes with a lot of challenges, like incorporating what their needs are.

Quote

Shared governance gives an opportunity to identify our needs or areas of opportunity, and allow the staff to decide: how are we going to overcome this as a unit, as a team?

Using our experienced nurses like Tonya—you know, being an assistant nurse manager and using her expertise— but also having the new nurses, who bring new perspectives and ideas, come together and create, quality measure plans for improving how we function in our unit.

allnurses: That really leads into the next question—how has this initiative improved staff satisfaction for you guys? Do you have any specific examples?

Tonya: Our scores as far staff satisfaction. Then the staff themselves and people who float to our unit have said that the camaraderie and the helpfulness of our staff has grown significantly. The whole atmosphere in the unit, people help each other a whole lot more. 

One of the things in our unit, we give out high fives, which is point system. When you get so many points, you can buy things online, but we give those to each other for helping out, for doing kind things. 

If one nurse doesn't want to float or doesn't have time to do something, and somebody else volunteers to take their patient to CT scan or whatever, they'll give them a high five. And in the mornings, we pass those out during our group huddle, and it's a way of thanking each other. And those have gone up significantly. 

Jamie: The team work in our unit is incredible. And like I said, it's challenging, and you know old school nursing everybody kind of did their own thing, it was everyone worked in silo type or independently. Now we see all different levels working together for the best interest of the patients. Watching my more experienced nurses support the new nurses and their success and helping them grow professionally. Participating in our clinical ladder program or our "PEP" program to better themselves, and push for certification and things like that. The shared governance is really the base for all of that, to bring everything to them, let them be more decision making as a group, and then coming to me and letting me help them make it come to reality. 

allnurses: So did I hear right, that you guys created "Wound Wednesday"? 

Tonya: Yes, that was one of our initiatives. 

allnurses: Tell me a little bit about what it is and how it works.

Tonya: In order to decrease the amount of bed sores that we had and to keep track of the ones that we didn't have, we decided on Wednesdays. We would take pictures of any wounds that patients had, and that we would also change all dressings on Wednesdays, all central line dressings. So we just called it "Wound Wednesday" so everybody could remember, okay, it's Wednesday this is what we do. It was also another way, if somebody comes in with a bruise or a rash or something like that, they would take pictures of that on the Wednesday so we could keep track of those things.

allnurses: That's great. As an assistant nurse leader, talk to me about your leadership style. Then second to that, the big buzz word I've heard from everyone I've interviewed is like mentorship. So if you can explain how that's important to your staff, and then again, your leadership style. We can separate them too. 

Tonya: Let's start with mentorship. That I have been helping a lot of people with the "PEP" program, our clinical ladder. That's something I feel is very important, it helps people develop, because you do different things in teaching and doing—like chart checks, which you go through the chart and see who charted things and ways to improve charting—which is also a way of developing their assessment skills and things like that. I've been going with pretty much all of the staff, individually, and talking to them about it, and showing them ways that they can earn points and things that they can do. 

Then I started thinking, "Well, what motivates me?” I like helping people, but I also like making money. So, I went through all of the people who report to me, and I wrote down their salary, and then I wrote down the first rung of the clinical ladder, how much money they would make if they did it, and the difference, and how much it would make per year. Then if they went on to the next level, the same thing, and to get to the next level one thing they need to do is get their certification in critical care. So, then I started talking to them about what they would need to do to study to get their certification. Then I have a study pack that I give them from when I took mine, and so I've started working with people. Then I started getting calls from other units wanting me to go down there and show them and help with it. We've had quite a few people go for that. 

allnurses: That's great. Then do you want to touch on leadership style?

Tonya:

Quote

I try to lead by example, I really do. I like the bedside, and I try to encourage people to do their best, to get involved and be part of the team.

allnurses: So how has the shared governance enhanced collaboration between ICU and the telemetry units, is it improving it? 

Tonya: Yes, because we have been working with them. Actually, what we did is I went to their leader, you talk about our relationship with management, I went to their leader, and I said, your charge nurses aren't comfortable with emergency situations. They're calling us in some situations that they could handle themselves, and then other times they kind of wait maybe too long or whatever. I said, "What if they come down and work in our unit, so that they can become familiar with these situations and know how to recognize when somebody's going bad, or how to treat".  So they started sending all their charge nurses down to work in our unit for a while, and that helped tremendously. I also encourage their charge nurses to call us. If you have a situation you're not sure about it, you don't know what to do, call us. We'll come up there and look at the situation and see, do we need to call a rapid response and get more help? Or can we just call the doctor and ask for this order? Or can we just do this and take care of this situation? So it has helped tremendously. 

allnurses: That's great. What are some of the biggest challenges you face as an assistant nurse manager in the ICU?

Tonya: Motivating staff. 

allnurses: Yea 

Tonya: I think this will help tremendously. I mean, we've gotten some great ideas here.

allnurses: Yeah. You guys are doing this for your hospital, are there plans to roll it out to others, or is it just kind of like everyone's in their own pocket and they're on their own to figure this out. 

Tonya: Our hospital is one of three that works together, and they've started shared governance with all three of the hospitals, and I happen to be chairperson for all three hospitals, and so, yeah, we're including them also. And the situation with the crash carts, we included the other two hospitals in that. 

Jamie: Yes, so she'll help roll out some of the initiatives that we've done to other units and the other sister facilities. She'll kind of take the lead on that, which is really awesome.

Tonya: When we get products like I've found here, and other products, I like gadgets, I get all excited over it. I take it when we do skills fair, I always teach at skills fair, and I take it to their hospitals and show it to them and have the numbers for them to order to have in their units too.

allnurses: What is in the future for the unit based shared governance? Like, what's the next steps? Or what does five years down the road look like?

Tonya: For each unit to have their own shared governance and to help develop their units, too. 

Right now, one of our big goals is to improve things between us and the ER. One of those things is just to improve our transfer times of moving our patients out, because they're always holding in the ER, because there's a waiting list of people to get in. So to try to improve our transfer times, so that we can move our patients to the floor, so they can get their patients out of the ER. They will appreciate us a lot more when we do that, because it's hard for them to hold patients down there for a long time. 

allnurses: I bet.  All right. Last question for both of you. What piece of advice would you give to new nurse managers in the ICU?

Tonya: Patience. It takes time. It takes time to develop people.

Jamie: I think, like you said before, lead by example. Be open, communicate, be collaborative. It's not a one person show. The unit cannot run by itself. It takes everybody. So be collaborative, be open, be positive. 

Tonya: Be positive. Yeah, we've all made mistakes.

Jamie: Yeah, and work and work as a team Really teamwork, I think, is the most important. I think that's why our unit is so successful, because we work as a team, regardless of what your title is.

Quote

We're all in it together for the best interest of our patients and the community, really. 

allnurses: Awesome, that's great. Thank you guys so much. 

Tonya & Jamie: Thank you.