Accepted: 9 April 2017

DOI: 10.1111/jonm.12500

ORIGINAL ARTICLE

Nurse manager perspective of staff participation in unit level

shared governance

Sheila Cox Sullivan PhD, RN, Director of Research and Analytics, Associate Adjunct
Professor1 | Mitzi R. Norris PhD, Executive Director for Academic Effectiveness2 | 
Lana M. Brown PhD, RN, NEA-BC, Associate Nurse Executive/Research3  | Karen J. Scott
MSN, RN, Deputy Associate Director/Patient Care Services/Nurse Executive3

1
VA Central Office-VACO, Washington, DC,
USA
2
University of Mississippi Medical Center,
Jackson, MS, USA
3
Central Arkansas Veterans Healthcare
System, Little Rock, AR, USA
Correspondence
Sheila Cox Sullivan, 810 Vermont Avenue
N.W., Washington, DC, USA.
Email: Sheila.sullivan2@va.gov
Funding information
This research was funded in part by a Faculty
Scholarship Exchange Award funded by the
University of Mississippi Medical Center.
Aim: To examine the nurse manager perspective surrounding implementation of unit
level shared governance in one Veterans Health Administration facility.
Background: Nursing shared governance is a formal model allowing nursing staff
decision-­
making input into clinical practice, quality improvement, evidence-­
based
practice and staff professional development. Unit level shared governance is a man-
agement process where decision authority is delegated to nursing staff at the unit
level.
Methods: Convenience sampling was used to recruit ten nurse managers who partici-
pated in face-­to-­face semi-­structured interviews. Data were analysed using content
analysis and constant comparison techniques. Demographic data were described using
descriptive statistics.
Results: The participants included seven female and three male nurse managers with
seven Caucasian and three African American. Participant quotes were clustered to
identify sub-­themes that were then grouped into four global themes to describe unit
level shared governance. The global themes were: (1) motivation, (2) demotivation,
(3) recommendations for success, and (4) outcomes.
Conclusion: These research findings resonate with previous studies that shared gov-
ernance may be associated with increased nurse empowerment, self-­management,
engagement, and satisfaction.
Implications for Nursing Management: These findings reflect the need for nurse man-
agers to promote and recognize staff participation in unit level shared governance.

KEYWORDS
nurse leadership, nurse manager, shared governance

1 |  INTRODUCTION of American University Press officially releasing a national statement

A form of shared governance termed university governance was first
introduced in The Yale Report of 1828 (Yale College, 1828). This influ-
ential document encouraged a collaborative environment between fac-
ulty and academic leadership to strengthen the foundation of academia.
Many universities adopted shared governance with the Association
highlighting support for university shared governance in 1925 (O’Neil,
2005). Anthony (2004) discussed the diverse theoretical underpin-
nings of shared governance from the 1960s through to the early 2000s
including “organisational, management and sociological theories” (p. 7).
Nursing shared governance was first introduced in the 1980s
as nursing’s collective response to the reorganisation of health care

J Nurs Manag. 2017;1–8. © 2017 John Wiley & Sons Ltd |  1

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2       COX SULLIVAN et al.
(Porter-­O’Grady & Finnigan, 1985). Nursing leadership’s responses to
changes in health care delivery included evaluating nursing care and
restructuring nursing delivery systems to reduce costs; improve patient
and employee satisfaction; and improve patient outcomes (Anthony,
2004; Bogue, Joseph, & Sieloff, 2009; Laschinger, Finegan, Shamian, &
Wilk, 2001; Ott & Ross, 2014; dos Santos et al., 2013). Healthy work
environments for nurses, quality patient care and job satisfaction are
closely linked, a fact which prompted health care administrators and
nurse leaders to develop strategies to promote healthy work environ-
ments (American Nurses Association, 2016). One of the eight char-
acteristics of a healthy work environment is nurses exercising control
over their practice, often referred to as shared governance (Kramer
& Schmalenberg, 2003). Shared governance has evolved over time
and is now defined as a decision-­making model designed to provide
nurses at all levels in an organisation with professional autonomy and
involvement in decision-­making processes, while inciting leadership
awareness and respect for the expertise of staff at the point of care
(McDowell et al., 2010).
Broadly, the phrase “shared governance” refers to activities at the
organisation or departmental level in which staff nurses are empow-
ered to participate in a meaningful way, thus improving patient out-
comes as well as nurse autonomy; decision-­making, satisfaction; and
recruitment and retention (Barden, Griffin, Donahue, & Fitzpatrick,
2011; Hauck, Griffin, & Fitzpatrick, 2011; Hess, 2011). Further, shared
governance is a tenet of Magnet® designation as described by the
American Nurses Credentialing Center (American Nurses Credentialing
Center, 2016). It is a structure that promotes nursing control of nurs-
ing practice through knowledge, partnership and accountability
(Kramer et al., 2010). O’May and Buchan (1999) analysed more than
500 articles to determine the meaning of shared governance at the
organisational as well as the unit level. This literature analysis revealed
that an overarching aim of shared governance is to empower nurses to
support the nurse–patient relationship.
Many facilities have taken shared governance an additional step by
placing the locus of control at the unit level. The purpose of unit level
shared governance (ULSG) is to reallocate the control of decisions
affecting practice at the unit level from the nurse manager (NM) to
the direct care nursing staff (Knutson, 2012). Processes and outcome
measures of this power shift are well documented in the nursing liter-
ature and include increased staff nurse commitment, improved work
environment, improved outcomes for patients and organisations, an
increase in nurses’ perceptions of empowerment, and enhanced pro-
fessional and organisational development (Brandt, Edwards, Sullivan,
& Zehler, 2012; McDowell et al., 2010; O’May & Buchan, 1999; Ott &
Ross, 2014). Unit level shared governance may establish its own sys-
tem and varied models may be used within one health care system
(O’May & Buchan, 1999).
A Veterans Health Administration (VHA) facility participated in
the Transforming Care at the Bedside (TCAB) Dissemination Initiative.
The original study, Transforming Care at the Bedside, conducted by
the Robert Wood Johnson Foundation and the Institute of Healthcare
Improvement, empowered direct care nurses to create change that
improved patient care and increased nursing time involved in value
added activities, such as direct patient-­
centred care (Martin et al.,
2007). The success of the TCAB project prompted the American
Organisation of Nurse Executives to develop a dissemination study to
facilitate the implementation of TCAB principals in health care facilities
(Needleman et al., 2016). This paradigm-­shifting activity encouraged
nursing leadership to implement ULSG throughout the medical centre.
Implementation of unit level shared governance at this VHA facility
empowered direct-­care nurses to perceive their engagement as genu-
inely directing nursing practice. Empowering individual nurses to make
seemingly minute decisions, such as where to install hand foam dispens-
ers, can dramatically influence work efficiency and staff satisfaction.
2 | BACKGROUND
The historical nurse manager role dates back more than 150 years to
the era of Florence Nightingale who recommended females as the
lead for nursing service (Wildman & Hewison, 2009). While the nurse
manager role has advanced to encompass all genders, nurse managers
or frontline supervisors are known for authoritatively directing nurs-
ing staff to achieve unit and organisational goals (Freed & Dawson,
2006). The nurse manager role includes unit level decision making
authority; therefore, implementing ULSG potentially results in a nurse
manager perceived loss of power.
Numerous articles discuss facility-­specific activities surrounding
the implementation of ULSG, but the evaluation of these activities
focuses primarily on the perception of staff nurses (Brandt et al., 2012;
Knutson, 2012; McDowell et al., 2010; O’May & Buchan, 1999; Ott &
Ross, 2014; Scherb, Specht, Loes, & Reed, 2011). Additional articles
discuss barriers associated with ULSG success, including role confu-
sion between staff nurses and nurse managers, inadequate leadership
support, insufficient recognition of achievement and staff attitudes
(Hess, 2011; Scherb et al., 2011). Hess (2011) cautions a steep learn-
ing curve for all involved when implementing ULSG, but suggests the
benefits are worth the effort. Brandt et al. (2012) highlighted actions
taken by nurse executives to promote the success of ULSG implemen-
tation. However, another possible explanation for variance in ULSG
implementation success is the perceptions of the nurse manager.
The literature supports nurse managers promoting positive rela-
tionships and building trust with frontline nursing staff, but there is
limited literature focusing on nurse manager guidelines related to
implementing and adapting to ULSG (Freed & Dawson, 2006). The
literature notes leading practices to promote the control of nursing
practice but provided little evidence or discussion as to how to give
nurse managers the tools to implement these practices (Kramer et al.,
2010; Wilson, Speroni, Jones, & Daniel, 2014). There is also a signifi-
cant disconnect between management and staff perceptions of shared
governance activities. Scherb et al. (2011) found that staff nurses
desired involvement in staffing decisions foremost, with liaison activ-
ities second and professional practice third. However, nurse manager
and staff nurse perceptions of actual involvement were significantly
different for ULSG (p = .039) and quality of staff support (p = .014)
(Scherb et al., 2011).
COX SULLIVAN et al. |
      3

Unit Level Shared Governance Interviews No. _______

1. Tell us how you implemented until level shared governance (ULSG) on your unit.

a. Role at implementation

b. Length of involvement

c. Process

2. What worked well about ULSG on your unit?

3. What didn’t work as well on your unit?

4. What are some specific examples of where ULSG was used on your unit?

5. What are some characteristics of nurses on your unit who DID embrace ULSG?

a. How were they motivated?

6. What are some characteristics of nurses on your unit who DID NOT embrace ULSG?

a. Did they understand the bigger picture of implementing ULSG?

7. What do you think about ULSG?

8. What suggestions would you make to other nursing units who are considering
F I G U R E   1   Interview Guide for Nurse
Managers implementing ULSG?

In summary, a review of literature did not yield empirical data
revealing what attitudes or practices of nurse managers contribute to
successful implementation of ULSG activities or guidance on how to
facilitate the development of characteristics for success among nurse
managers. Thus, the purpose of this qualitative pilot study was to
examine the nurse manager perspective surrounding implementation
of unit level shared governance in one VHA facility.
3 | METHODS
After receiving Institutional Review Board (IRB) approval, conveni-
ence sampling was used to recruit nurse managers for this pilot
study. Thirty nurse managers at this VHA facility who had partici-
pated in unit level shared governance were invited to participate in
the qualitative interviews. For the purposes of this study, our team
defined nurse manager as a nurse responsible for supervising a
group consisting primarily of staff nurses, not necessarily limited to
a geographical area. The teams these managers oversaw varied from
all registered nurse (RN) staff to a mix of RNs, Licensed Practical
Nurses (LPNs) and Unlicensed Assistive Personnel (UAP). Each nurse
manager received a letter stating that they would be contacted by
the research team via telephone to discuss study participation. The
letter included the IRB-­approved informed consent document (ICD)
to allow participants to review the ICD prior to the telephone con-
versation. The letter also contained instructions to allow the nurse
manager to opt out by notifying the principal investigator by email
or phone. The principal investigator began calling eligible nurse
managers who did not opt out between 10 to 15 days after the email
to discuss the study and to make an appointment. Actual informed
consent did not occur until the participant arrived for the scheduled
interview.
Eleven nurse managers responded to the request for interviews,
a 37% response rate. Participants had to be a nurse manager at this
facility and to have participated in the ULSG structure. Ten nurse
managers came to the scheduled interview appointments for a 33%
response rate after one nurse manager was ill and was not at work
at the designated time for her interview. Demographic data collected
from the participants included race, education level and years of nurse
manager experience. The nurse managers participated in 50-­min face-­
to-­face interviews using a semi-­structured guide to elicit the attitudes
and management strategies employed by the nurse manager on units
implementing ULSG (see Figure 1). The team conducted interviews in
a private room within the facility, with two of the three investigators
present for each interview. The investigators planned to audio-­record
the interviews and proactively verified that the audio-­recorder was
functional with new batteries. At the time of the interviews the audio-­
recorder malfunctioned, and the investigators were unable to audio-­
record participant responses. Interviews were not rescheduled due to
the interviews being pre-­scheduled and to respect the nurse managers
scheduled time away from the unit and one of the investigators trav-
elled from out of state to participate. Two investigators were present
at each interview, and written notes were taken with the aim to take a
full written version of each interview. The two investigators reviewed
the written transcripts immediately after each interview to compare
for accuracy.
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4       COX SULLIVAN et al.

Global Themes/Sub- Number Raw data quotes

Themes (n = 10)
Motivation 10 ‘When they encountered change and saw the benefit, they
• Internal were more interested in participation.’
contributing factors ‘It must be something important to them so they can see a
change.’
• External 8 ‘Our doctors were supportive and impressed by our
contributing factors innovative changes. Being recognized became a big part.’
‘It was their baby. Their voices were heard.’
Demotivation 3 ‘Some staff said this is not my job. It is the nurse
• Internal manager’s job.’
contributing factors ‘Some of them drag their feet and will not get involved.’
• External 6 ‘The staff got frustrated with directives that you must
contributing factors always be working on something.’
‘Over formalizing Unit Level Shared Governance is a
problem.’
‘It has been a struggle with Unit Level Shared Governance
leader succession planning.’
Recommendations for 10 ‘Share your successes.’
success ‘They were empowered to do what they wanted to do.’
• Nursing leadership ‘Mentoring and facilitation never goes away.’
• Nursing staff 6 ‘The key is staff buy-in.’
‘Practice makes perfect.’
‘Once they taste success, it will move forward.’
Outcomes 10 ‘Self-scheduling came from Unit Level Shared
• Project successes Governance. They wanted more scheduling input for the
last six years.’
‘Due to seeing more female patients, they worked to make
breast feeding and milk storage safe. The nurses did it all.’
• Serendipitous 4 ‘It’s not about the person, it’s about the process.’
outcomes ‘Unit Level Shared Governance builds more leaders and a F I G U R E   2   Thematic Analysis of
better programme.’ Interview

The interviewers began with a brief introduction including the
purpose of the study. The first question asked of participants was,
“Tell me the story of how you implemented ULSG on your unit.” Probe
questions were used to gain additional knowledge on implementation
of ULSG. Member checking, a way to validate the investigator under-
standing or to clarify participant comments, occurred at the end of
each interview (Robert Wood Johnson Foundation, 2008).
Demographic data were analysed using descriptive statistics.
Interview data were analysed using content analysis and constant
comparison techniques. Content analysis, a systematic method of
coding and analysing qualitative data, was used to explore clear and
hidden meanings within the text (Bernard & Ryan, 2010). A code book
with precise definitions for each code was developed and ­continually
re-­
­ evaluated for coding accuracy. Two experienced research-
ers reviewed the codes and definitions to enhance dependability.
Constant comparison is the method of breaking down interview data
into smaller data and comparing these data between interviews to
compare and contrast codes and themes and group content into sub-­
themes and global themes (Dye, Shatz, Rosenberg, & Coleman, 2000).
Participants’ direct quotes were used to describe ULSG (see Figure 2).
4 |  RESULTS
The participants included seven female and three male nurse manag-
ers, seven of whom were Caucasian and three were African American.
Management experience ranged from 1 year to greater than 20 years
with five nurse managers being master’s prepared and five nurse
managers having a baccalaureate degree. The investigators clustered
participant quotes to identify sub-­themes subsequently grouped into
four global themes to describe ULSG. The global themes were: (1)
motivation, (2) demotivation, (3) recommendations for success, and
(4) outcomes. The sub-­themes for both global themes motivation and
demotivation included internal and external contributing factors that
motivated or demotivated nursing staff to participate in ULSG. The
theme recommendations for success included the sub-­themes com-
prising nursing leadership and nursing staff. Project successes and
serendipitous outcomes were sub-­themes used to address the global
theme outcomes.
4.1 | Motivation
Motivation is defined as reasons for nursing staff to participate in unit
level shared governance. This included internal and external contrib-
uting factors that motivated nursing staff to participate in the ULSG
structure and project development.
4.1.1 | Internal contributing factors
Internal contributing factors, circumstances originating from within
the staff nurse, included internal recognition and self-­reward. Staff
nurses became energized through creating processes to improve
quality or streamline the required effort to accomplish their work. The
nurse managers relayed the following comments from nursing staff
regarding ULSG participation: “Activities were rewarding in them-
selves’ and ‘Motivation came from encountering change.” The nursing
COX SULLIVAN et al.
staff were self-­motivated to create positive changes for veterans and
staff. One nurse manager stated, “I saw increased staff satisfaction
by helping others.” Age and experience may also predict the involve-
ment of nurses in this governance structure. The nurse managers
stated that younger, less experienced nursing staff were more likely
than nurses near retirement to be active ULSG participants. The nurse
manager comments regarding nursing staff who participated in ULSG
included “Those who participated demonstrated leadership qualities”;
“They were the young, charismatic risk-­takers”; and “It was the newer
staff who were the dinosaur slayers.”
4.1.2 | External contributing factors
External contributing factors, circumstances outside of the nurs-
ing staffs’ control that led to USLG participation included positive
leadership behaviours; promotion; recognition and rewards; and
positive peer pressure. Areas with supportive nurse leaders were
more likely to participate in the ULSG structure. One nurse man-
ager commented: “You have to promote your staff. I can’t say that
enough. That’s the whole thing.” The nurse managers felt nursing
staff were most likely to engage in ULSG projects if the nurse man-
ager supported the project and removed roadblocks as needed to
enhance project success. These supportive nurse managers rou-
tinely praised the ULSG team members. One supportive nurse
manager stated, “Give the staff credit for everything. Every, every,
every, everything.”
Potential promotions within the organisational clinical ladder
motivated nursing staff to participate in the structure. Nursing staff
were recognized and rewarded for their collaborative efforts in
ULSG ­projects, including verbal recognition by leadership along with
announcements at nurse manager monthly meetings. Quarterly rec-
ognition ceremonies allowed upper leadership to present certificates
and recognize staff. Rewards included compensatory time off, a “Big
Blue Ribbon” award that moved between areas, and poster/podium
­presentations developed from projects. One nurse manager gave out a
“good egg” award. Each manager recognized this type of positive peer
pressure as a factor in motivation. This peer pressure was described
as leading to “increased camaraderie” and “positive feelings of team-
work.” When ULSG worked well, participants described it as “increas-
ing trust in each other and management.”
4.2 | Demotivation
Demotivation is defined as reasons nursing staff choose not to partici-
pate in ULSG. It included circumstances that mitigated nursing staff
participation in ULSG. Nurse managers explained internal and external
contributing factors that resulted in staff demotivation.
4.2.1 | Internal contributing factors
Internally, staff became discouraged when ULSG projects did not
accomplish the desired results. Several nurse managers said to start
small with one stating “The staff sometimes felt like failures if they
|
      5
were not initially successful”. Many managers explained that at the
beginning of the ULSG projects not all projects would have the
expected or desired outcomes. One nurse manager stated “Unit Level
Shared Governance is a process. It is an opportunity to try but not
everything will work.”
4.2.2 | External contributing factors
The nurse managers identified several external factors from outside of
the nursing staff that induced staff demotivation. These factors were
the amount of required paperwork, limited time and negative leader-
ship behaviours. Nursing staff perceived the amount of organisational
paperwork required for ULSG projects to be lengthy and cumber-
some. Comments made by nurse managers included: “Paperwork took
the fun out of the initiatives” and “Required monthly reports made it
a duty, not a privilege.”
Patient care is and should be the primary focus of nursing staff.
Nursing staff often felt providing excellent patient care did not leave
enough time to focus on ULSG projects. Some of the staff com-
plaints regarding limited time included: “Meetings were spur of the
moment and not always planned” and “It pulled nurses away from
direct patient care.” One nurse manager described ULSG as “It was
kind of like pulling teeth. Everyone was for it, but no one wanted to
spend the time.”
The final demotivator identified was nurse manager negative
leadership behaviours including discipline for lack of participation,
favouritism for active participation, and staff not being recognized for
ULSG project implementation success. There were nursing staff that
described ULSG to a nurse manager as, “Just another fad.” A nurse
manager commented, “If the nurse manager doesn’t believe in it, it
won’t happen.” Some nurse managers mandated ULSG topics instead
of the allowing the nursing staff to initiate ideas leading to staff nurse
resistance.
4.3 | Recommendations for success
Recommendations for success were defined as suggestions from
the nurse managers on the best course of action to implement ULSG
and to encourage nursing staff participation. Nursing staff participa-
tion in ULSG begins with thorough education and understanding of
the ULSG structure. According to one nurse manager, “there should
be education on Unit Level Shared Governance in orientation with
follow-­up in monthly staff meetings.” They stated that ULSG has
to be nursing staff driven not leadership driven, empowering staff
to choose the ULSG projects. This process was described as the
ideas “need to bubble up from the bottom.” One nurse manager
explained, “Everyone is important, and we should listen to every-
one’s voice.”
Nurse leaders should observe from a distance, staying out of the
way to increase staff autonomy and ensure recognition/rewards for
project success. Nurse managers need to understand their nursing
staff to know what will rewards, recognition and frameworks will work
best.
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6       COX SULLIVAN et al.
4.3.1 | Nursing leadership
The nurse managers explained their recommendations for ULSG
success and described the nurse manager role as being a mentor/
facilitator. A nurse manager explained “With ULSG, the nurse man-
ager must be willing to take the risk to give staff the opportunity to
grow.” The nurse managers supplied education and the tools needed
to support the ULSG structure. Many recommended beginning ULSG
with a small, staff-­driven project with a high probability of success to
contribute to the nursing staff feeling accomplished and encouraging
further participation. The nurse manager collaborated with the staff
to identify project barriers and to assist them through organisational
hurdles. One nurse manager described it as, “Mentoring from a dis-
tance to just give them what they need to succeed.” The nurse man-
ager assists the ULSG by knowing what is happening throughout the
organisation to avoid duplication of project initiatives.
The nurse managers discussed the importance of building lead-
ership skills and encouraging growth of ULSG nursing staff. For areas
with multiple shifts, they strongly encourage having ULSG leaders
from each shift to assist with engaging more staff members, antici-
pating that informal leaders will arise from various shifts. One state-
ment was to “rotate leadership among staff on an annual basis to avoid
burnout.” The nursing staff ULSG leader should be able to communi-
cate effectively with all staff. Teamwork is essential to ULSG success.
Allow ULSG to be an arena for staff to voice concerns, gain staff buy-­in
and share project successes.
While discussing ULSG nursing staff project perspectives with
nurse managers from varied specialty areas, nurse managers verbal-
ized that the nursing staff members who were encouraged to develop
their own ULSG projects became more excited about ULSG and fol-
lowed through on projects. One nurse manager noted, “The nurse
manager must step back. It must be staff driven.” Another nurse man-
ager described a staff project she promoted, noting that she needed to
allow the idea to belong to the staff members rather than overly guide
the process, even when she suspected the proposed steps would not
succeed. She stated, “It would have been more disruptive to persuade
than to just allow it to evolve.” She concluded the staff’s sense of own-
ership was more important than showing she was right.
4.3.2 | Nursing staff
The nurse managers explained that the majority of nursing staff
focused internally on unit projects influencing staff and patients
within their area, while a small number of nursing staff focused on the
bigger picture recognizing how ULSG projects impact nursing staff,
veterans and the organisation on a larger scale. The nurse manag-
ers described nursing staff overall as, “They could not see the impact
beyond their own unit.”
The nurse managers observed that nursing staff emerge as lead-
ers through ULSG. The staff was empowered to initiate change within
the organisation. The staff were aware that ULSG boundaries, such
as organisational policies had to be followed. One nurse manager
stated, “Staff should have the freedom to make decisions, but they
must operate within the guidelines.” Peers began to document each
other’s accomplishments for recognition through the ULSG process. A
nurse manager noted, “Rewards were that we recognized each other.”
4.4 | Outcomes
Outcomes were defined as consequences of nursing staff participa-
tion in unit level shared governance. These outcomes included project
successes that improved veteran care as well as staff processes and
serendipitous outcomes of ULSG.
4.4.1 | Project successes
The ULSG project successes ranged from employee focused to vet-
eran focused to organisation focused. Examples of ULSG project
successes were improvements in catheter associated urinary tract
infections, central line associated blood stream infections, ventilator
associated pneumonia and hospital acquired pressure ulcers. One
nurse manager stated “They (staff) changed patient education materi-
als based on the evidence.” Another nurse manager noted, “They saw
the veterans waiting for the bus out in the rain. The nurses organised
a free bus shelter.” Other examples included “The hand off template
developed by our ULSG is now used house wide” and “They reorgan-
ised the supply room after reviewing product use.”
4.4.2 | Serendipitous outcomes
The nurse managers described serendipitous or unexpected outcomes
of ULSG. There was a common misperception among nursing staff, as
noted by two nurse manager statements, that “ULSG is for RNs only”
and “It was an RN thing”. Allowing participation and input from RNs,
LPNs and UAPs in ULSG activities led to increased camaraderie and
teamwork within the department and improved veteran outcomes.
One nurse manager stated “It was everyone’s responsibility. Everyone
can contribute.” A nurse manager described it as “Now it is possible,
and they are crazy on fire.” When this VHA facility incorporated ULSG,
the nurse managers did recognize the negative impact staff turnover
could have on the ULSG structure and processes. One nurse manager
explained “Leadership should be rotated yearly so that the next leader
can be groomed.” Once the impact was recognized, the ULSG commit-
tees were able to incorporate leader succession planning thus growing
more formal and informal unit leaders.
5 | DISCUSSION
The aim of this qualitative pilot study was to examine the nurse man-
ager perspective surrounding implementation of unit level shared
governance. The global themes, sub-­
themes and strategies dis-
cussed by nurse managers resonate with findings from other current
research that shared governance may be associated with increased
nurse empowerment, self-­management, engagement and satisfaction
(Bogue et al., 2009; Laschinger et al., 2001; Ott & Ross, 2014; dos
COX SULLIVAN et al.       7 |
Nurse manager unit level shared governance implementation strategies (n = 10)

Strategies to motivate nursing staff

• Nurse manager serves as an advocate, mentor and resource to remove barriers (10)
• Positive peer support and teamwork (10)
• Reward and recognize staff for ULSG participation and outcomes (8)
• Allow nursing staff autonomy to develop project ideas within their scope of practice
(7)
• Share ULSG successes broadly (6)
• Nurse manager with clear, supportive education and tools to promote ULSG (5)
• Begin with small projects then move to larger projects (5)
• Allow staff time to participate while maintaining unit coverage (3)
• Allow flexibility for ULSG to vary between units (3)
Strategies to avoid that demotivate nursing staff
• Authoritative nurse manager leadership style (7)
• Lack of time to participate (6)
• Excessive required paperwork (5)
• Rigid ULSG structure (5)
• Lack of ULSG staff understanding (5) F I G U R E   3   Nurse manager unit level
• Discipline for lack of ULSG participation or favouritism for participation (3) shared governance implementation
• Peer shaming or embarrassment for participation or for failed projects (3) strategies (n = 10)

Santos et al., 2013). This study correlates with the findings of Ott and
7 | SIGNIFICANCE OF THE STUDY
Ross (2014) who studied the lived experience of initiating shared gov-
ernance at a facility level. They described the transition as a journey
Understanding the characteristics of nurse managers who are able to
that led to increased patient satisfaction, empowerment of nursing
implement unit level shared governance effectively may allow nurse
staff and increased self-­management by staff. Our study differed from
managers within other health care facilities to use these recommen-
that of Ott and Ross (2014) in two critical ways: (1) this study focused
dations for ULSG implementation: (1) provide education on ULSG
on initiation of shared governance at the unit level rather than facil-
structure and processes, (2) allow nurse leaders to emerge from ULSG
ity wide, and (2) this study concentrated on strategies managers can
participants, (3) allow nursing staff to propose and develop change, (4)
employ at that level to enhance success and empowerment for the
nurse managers to serve as a mentor or in a support role, and (5) rec-
staff. A recent survey by Wilson et al. (2014) demonstrated consist-
ognize and reward nursing staff. Understanding what characteristics
ency with our findings that: (1) leadership support is essential and (2)
contribute to ULSG success may allow organisations to develop nurse
prioritizing patient coverage to release nurses to participate without
manager competencies and interventions to guide and grow nurse
increasing the workload on peers and compromising patient care is
managers in this area.
vital.
What this study adds to the literature is pragmatic strategies from
nurse managers who successfully implemented unit level shared gov-
ernance models as part of a facility cultural change (see Figure 3). The
8 | IMPLICATIONS FOR
study also supports the findings of recent studies that discuss moti-
NURSING MANAGEMENT
vational factors for and against engagement in shared governance
The nurse managers supported staff participation in ULSG within a
activities.
VHA facility may lead to empowerment of nursing staff to develop
meaningful improvements in their work. According to nurse manag-
ers, nursing staff must be allowed to make decisions and to develop
6 | STUDY LIMITATIONS
projects for improving veteran care. Nurse managers should serve
as facilitators assisting nursing staff as needed or removing project
Several study limitations need to be noted. This was a small pilot study
implementation barriers, but nurse managers should not lead ULSG in
including a sample size of ten nurse manager participants recruited
an authoritative manner. More research is needed on the successful
from one southern VHA health care facility. Other VHA facilities or
implementation of ULSG structures.
organisations outside the VHA system may have different results.
The second study limitation is that the interviews were not audio-­
recorded due to an equipment malfunction. Audio-­recording would
AC KNOW L ED G EM ENTS
have allowed the investigators to maintain eye contact, concentrate
and respond better to the participants, allowed for verbatim transcrip- This material is the result of work supported with resources and the
tion of the interviews and reduced the potential for researcher bias. use of facilities at the Central Arkansas Veterans Healthcare System.
 |
8       COX SULLIVAN et al.

ET HI CAL APPROVAL settings: Expanding Kanter’s model. Journal of Nursing Administration,

31(5), 260–272.
This study was approved by the Institutional Review Board and Martin, S. C., Greenhouse, P. K., Merryman, T., Shovel, J., Liberi, C. A., &
Research and Development Committee of the Central Arkansas Konzier, J. (2007). Transforming care at the bedside: Implementation
and spread model for single-­hospital and multihospital systems. The
Veterans Healthcare System. This material is the result of work sup-
Journal of Nursing Administration, 37(10), 444–451.
ported with resources and the use of facilities at the Central Arkansas
McDowell, J. B., Williams, R. L., Kautz, D. D., Madden, P., Heilig,
Veterans Healthcare System in Little Rock, Arkansas, USA. A., & Thompson, A. (2010). Shared governance: 10 years later.
Nursing Management, 41(7), 32–37. https://doi.org/10.1097/01.
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