1. Porter-O'Grady, Tim DM, EdD, ScD(h), APRN, FAAN, FACCWS

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I read with interest the guest editorial by Robert Hess.1 It was both renewing and rewarding to read a brief history of his journey with shared governance and reflect on insights related to its foundation and substance from his perspective. I celebrate his insights and want to affirm my own support of them and his reflections related to shared and professional governance principles and practices. The growth of understanding about governance of a profession as applied to nursing and nurses is the product of having been informed and exposed to a diversity of scholarship and approaches for the past 33 years since Sharon Finnegan and I wrote the seminal text Shared Governance for Nursing in 1984.2 Hess' work during the years has added to that body of knowledge, an effort that we should all celebrate.


Although I have nothing to contest in his excellent editorial, I do have some additional insights to share. The origins of formal work on shared governance by both Christman and myself have been in response to a fundamental conflict between employee-based organizational work structures that treat all work as a subset of the employment relationship and professional drivers that define membership as a social mandate.3-5 This social mandate places accountability and the locus of control for action in the member of the profession as a condition of membership, not as an element of employer direction or control. Indeed, one of the unique characteristics of a profession is that professionals act out of the social mandate for their profession and rigorously eschew institutional control and ownership of their work.6 Although this understanding formed the foundations for most professions (notably, law, medicine, architecture, engineering, ministry, etc), it was not ever considered as legitimate when applied to nurses.7 Because nursing has been a predominantly employed work group primarily composed of women, the usual requisites of ownership, control over practice, and membership were rarely applied to nurses. For already well-documented reasons, such equity-based approaches have never been historically legitimized for nurses.8


When beginning formal organizational efforts to implement nursing governance models in the 80s in the 1st 3 hospitals in the Unites States, St Joseph's Hospital of Atlanta, St Michael's Hospital in Milwaukee, and Rose Medical Center in Denver, the term professional governance was seen by administration at the time as an emotionally charged code for what was often called by the legal departments and human resources of these institutions as an "in-house union." In an effort to find a more palatable term that would not generate such images in these leaders, the term shared governance was found to be a less "charged" or offensive term. Although governance also generated much angst and intense discussion, for the most part, it was generally reluctantly tolerated when applied to nurses. Such were the conditions of the time. The term shared did not fully or adequately express the processes we were initiating, but it did create a safe landscape where the principles and processes grounding the related structures of nursing professional governance could safely begin. The use of the term shared rather than professional at the time was expediency, nothing more and nothing less.


That the concept and models of nursing governance rapidly grew was certainly a testament to the hunger for a professional framework that would express nursing professional membership and the implied ownership and accountability for nursing practice. The generally acceptable rubric under which this activity has occurred for the past 30 years has been notably "shared," not "professional governance," almost exclusively that term enumerates most organizational structures related to nursing governance activities. However, it is the product more of habit than of accuracy.


Next, it is important to distinguish professional governance from a management model, system, or technique for managing nursing. It is, in fact, none of that. Professional governance, in fact, distinguishes itself from management functions as a mechanism for professions to not be controlled or managed by organizations or those outside the profession. One of the unique characteristics of professions is that they are self-managed and have exclusive control over their own practice and work as partners with organizations and others in meeting the needs of those they mutually serve. Their relationship is an agreement, not a hierarchy. As an example, in hospitals, the medical staff works as a partner with hospital leadership within a set of bylaws that carefully lays out the governance of the independent medical staff and its partnership relationship with the hospital. Typically, no such collateral relationship exists with the profession of nursing. It was certainly in the interest of attempting to successfully clarify and apply these factors for nursing as a profession that has driven governance work with nurses in hospitals for the past 33 years. One of the current signposts that our progress remains slow is that advanced practice nurses, educated as nurses, licensed as nurses, examined as nurses, and certified as nurses, must be approved by the medical staff for these nurses to act on nursing privileges to practice within their scope of practice. Although considerable progress has been made, even in shared governance structures, nursing still has not reached true professional equity.


It is true that moving to using the term professional in place of shared is neither new nor unique. In truth, it is now merely safer to do so than when governance concepts were 1st applied to nursing. What is new is the requisite to examine nursing professional governance within the full scope of what the term means, without accommodation or equivocation. We can now define professional nursing governance as "the accountability, professional obligation, collateral relationships, and decision-making of a professional, fundamental to autonomous practice and the achievement of empirical outcomes."9 Language is important and so is what it implies. Theory, models, applications, instruments, and research now must begin to use comparable generally acceptable concepts and terms that represent what is understood about the contemporary rights, roles, structures, and processes associated with professionals fully equitable in governing their practice and relationships. As Magnet(R) hospitals have evolved and we are now seeing institutions of excellence pursuing 4th, 5th, and 6th redesignations, they now must begin to show that professional nurses are self-governing, interdependent, and equitable in ways that demonstrate ownership and accountability for their own practice decisions and demonstrate measurable contribution to the value and sustainability of the health of those we serve.


What is also true is Hess' assertion1 that we must now think more robustly about interprofessional governance. What makes interprofessional relationships work however is both an even and equitable table at which all members collaterally participate and the expectation that each is clear about the role, contribution, and value each brings to the table. Not having done that work inside each discipline, getting to the table does not guarantee that anything purposeful will come from the deliberations there.


Nursing has clearly grown stronger and more equitable for the past half century. No doubt, shared governance has contributed in no small measure to this journey. Whether it grows further depends on a number of variables, one of which is how fully autonomous, clear, and accountable nurses are in enumerating their contribution and value to sustainable health. Further refining and expanding structures, models, and processes of professional governance will add the supporting infrastructure for this next work. Moving from shared to professional governance for nursing is not a trivialization or termination, it is instead a transformation. One thing upon which we can all agree on-nursing governance has always been that.




1. Hess RG. Professional Governance: Another New Concept? J Nurs Adm. 2017;47(1):1-2. [Context Link]


2. Porter-O'Grady T, Finnigan S. Shared Governance for Nursing: A Creative Approach to Professional Accountability. Rockville, MD: Aspen Systems; 1984. [Context Link]


3. Christman L. Hospital Organization and Healthcare. Rockville, MD: Elsevier Publishers; 1982. [Context Link]


4. Christman L. The autonomous nursing staff in the hospital. Nurs Adm Q. 1976;1(1):37-44. [Context Link]


5. Porter-O'Grady T. Implementing Shared Governance: Creating a Professional Organization. Rockville, MD: Aspen Systems; 1992. [Context Link]


6. Porter-O'Grady T. Interdisciplinary Shared Governance: Integrating Practice, Transforming Healthcare. Boston, MA: Jones & Bartlett; 2009. [Context Link]


7. Ashley J. Hospitals, Paternalism, and the Role of the Nurse. Teachers College Press; 1976. [Context Link]


8. Mason D, Isaacs S, Colby D. The Nursing Profession: Development, Challenges, and Opportunities. San Francisco, CA: Jossey-Bass; 2011. [Context Link]


9. Clavelle J, Porter O'Grady T, Weston M, Verran JA. Evolution of structural empowerment: moving from shared to professional governance. J Nurs Adm. 2016;46(6):308-312. [Context Link]