THE JOURNAL O F NURSING ADMINISTRATION C-Suite

THE JOURNAL O F NURSING ADMINISTRATION C-Suite Roles and Competencies to Support a Culture of Shared Governance and Empowerment M. Lindell Joseph, PhD, RN Richard J. Bogue, PhD, FACHE Please summarize the journal OBJECTIVE: The aim of this study was to examine C-suite executives” perspectives on empowerment early in shared governance implementation. BACKGROUND: Leadership influences a workplace culture for empowerment. However, the literature lacks clarity regarding the specific roles of C-suite executives in fostering empowerment. METHODS: A system”s top 47 executives were invited to participate in a Delphi study. Two Delphi rounds identified leadership empowerment philosophies, plus techniques for (a) understanding staff needs, (b) embedding empowerment, and (c) ensuing leadership accountability. In round 3, leaders rated the 3 types of techniques for ease and impact. RESULTS: Results revealed a passive C-suite culture regarding empowerment. However, C-suite executives recognized the need for active promotion of an empowering culture. Optimal techniques for understanding staff empowerment needs were identified. CONCLUSIONS: Modeling empowerment by the C-suite executives enables alignment between councils and levels of nursing leadership, allowing organizations to achieve the goals for professional nursing practice and shared governance. Achieving organizational excellence begins with the creation and/or implementation of systems, infrastructures, or methodologies, supported by tools and Author Affiliations: Clinical Professor and Director, MSN/CNL Program (Dr Joseph) and Associate Clinical Professor (Dr Bogue), College of Nursing, The University of Iowa. The authors declare no conflicts of interest. Correspondence: Dr Joseph, 466 CNB, 50 Newton Rd, Iowa City, IA 52242 DOI: 10.1097/NNA.0000000000000635 strategies to enable the achievement of a desired workplace culture. The primary mechanism for influencing workplace culture is leadership. This mechanism includes the actions and behaviors of leaders, what gets rewarded or discouraged by the leaders, and where leaders allocate resources. Secondary mechanisms that influence culture are systems, procedures, rituals, physical space allocations, and an organization”s formal communications, such as the mission statement.1,2 As noted by Kanter,3(p177) BIn contrast to traditional views of power as coercion or domination, power is the ability to get things done.[ The ability to get things done is referred to as goal attainment.4-6 Commonly promoted approaches to empowerment of nurses and nursing in hospitals are often collectively labeled nursing shared governance.7,8 To fully execute shared governance, organizations require alignment between the workforce, leadership, and resources at the microsystem, mesosystem, and macrosystem levels.5,7 Alignment is defined as the degree to which the components of an organization are optimally arranged to support the purposes, goals, and objectives of the organization.7 Organizational alignment is both a process and an outcome. Building and ensuring organizational alignment require focused and ongoing effort up and down and across levels.9 Nursing shared governance is viewed as the process for achieving vertical alignment of nursing leadership group power and the empowerment practices of nurse practice councils at the various levels of organizations.7,8 To enable shared governance effectiveness, all levels of leadership must provide participants with necessary assets: time, encouragement, forums for communication, resources, and information.3,4 Two key terms that are important in fostering empowerment JONA Vol. 48, No. 7/8 July/August 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. 395 are the perspectives and the roles of the C-suite and their direct reports. C-suite refers to top senior executives with the letter C, for chief, as in chief executive officer, chief financial officer, chief operating officer, chief nursing executive (CNE), and chief information officer.10 Executive leadership of a 2400-bed, 8-hospital health system in the southern United States engaged the authors to study the effectiveness of the nursing practice councils that had recently been established. A survey of frontline nurses and unit managers revealed that frontline nurses perceived higher levels of empowerment than did their frontline leadership.7 To understand expectations about what empowerment means in practice and how nurse empowerment is fostered at different levels of the organizational hierarchy, the researchers examined the empowerment philosophy and strategies of leaders from the C-suite and their direct reports. This article focuses on the C-suite members” philosophy of empowerment, how they perceive workers experience in terms of power and empowerment, and how the leadership team can best learn from and show the workforce about empowerment successes and areas for improvement. The study was deemed exempt by the organization”s institutional review board. Methods This study used the Delphi technique.11-13 In Delphi, participants respond independently, and each round of questioning is based on results from prior rounds, permitting increasingly precise understanding of a group”s knowledge or perspective. Delphi is suited to gaining a collective and relatively unbiased view of organizational leaders” ideas related to empowerment. Delphi helps avert certain sources of error that often emerge through group dynamics, such as domination of results by a vocal few or biases reinforcing preconceived notions. A purposive sample of 47 C-suite executives was identified throughout the 8-hospital system. They included the CNE, a nurse vice president (VP), assistant VPs and VPs of other clinical areas, and chief executives in finance, operations, and management. Three rounds of Delphi surveying were sent to these 47 system leaders for this study. Each round”s prompts that are relevant to this article are as follows: 1. Round 1: Twenty-six panelists consented; 24 responded to at least 1 of 3 prompts designed to understand the organizational leadership”s philosophy of empowerment. a. BWrite 1 sentence characterizing this system”s philosophy on the empowerment of the workforce. What does the organization”s leadership want the system”s workforce to experience in terms of power and empowerment?[ b. BGiven the realities faced day in and day out and the fact that many factors are outside our control, what we want is often not what we get. Write 1 sentence that describes, in your honest general view, how the system”s workers actually experience power and empowerment?[ c. BIn a sentence, on what evidence is your response to question 1b based? How did you come to this conclusion? What have you seen or heard or otherwise observed that taught you this?[ 2. Round 2: Twenty-five panelists consented; 22 offered techniques to foster workforce empowerment in response to the following prompts: a. BIn 1 or 2 sentences, how should leadership, like you and your peers, sense the empowerment needs of the workforce? That is, how can leadership best learn from and show the workforce about their empowerment successes and areas for improvement?[ b. BBriefly, what 1 or 2 specific actions should members of leadership, like you and your peers, take to embed and reinforce empowerment among the system”s workers?[ c. BIn a sentence or 2, in what specific way should members of leadership, like you and your peers, assess their own performance in the empowerment of the workforce?[ 3. Round 3: The 22 panelists responding in round 2 were surveyed; 15 rated the techniques identified in round 2. All 3 types of techniques were rated on ease of implementation and likely magnitude of impact using 5-point Likert-type scales: ease (very easy to implement, easy to implement, moderately easy to implement, difficult to implement, very hard to implement) and effectiveness (very major impact, substantial impact, moderate impact, some impact, little or no impact). a. BWhat techniques should leadership use to determine the empowerment needs of staff? b. BWhat strategies should leadership use to embed and reinforce empowerment behaviors among staff? c. BWhat strategies should be used to ensure leadership accountability for worker empowerment?[ Results C-Suite”s Philosophy of Empowerment Round 1 of the Delphi solicited C-suite panel members” desired state of empowermentVwhat leadership aspired for the workforce to experienceVand their JONA Vol. 48, No. 7/8 July/August 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. 396 views of the actual stateVhow they think the workforce actually experienced empowerment at that time. Nearly all statements revealed that the organization”s leaders understood and valued empowerment and expected workers to act empowered. However, the C-suite did not identify active roles for themselves at the level of frontline managers and the workforce in the then-current environment of empowerment. Examining C-suite impressions of how the workforce experienced empowerment identified a number of barriers to actualizing empowerment. Many of the statements assumed staff should already know they should act empowered, those with a professional license should feel empowered, and that leadership want staff to be and feel empowered without active executive engagement. Illustrative statements included the following: BEvery staff member should understand that he/she is empowered to ensure the system”s mission is central and demonstrated[ and BAt the VP level, their philosophy is to give power away and allow the frontline teams to make as many decisions as possible.[ Table 1 offers example statements from C-suite executives illustrating passivity-related barriers to empowerment up-and-down levels of the organization. C-Suite Techniques for Identifying Staff Needs for Empowerment Round 2 gathered C-suite suggestions for specific techniques to advance empowerment. Participants Table 1. C-Suite Perceived Barriers to Empowerment at Then-Current State Barrier Level Exemplars Systemic level 1. People get bogged down with details that distract from appreciating the big picture 2. Bureaucracy sometimes limits the ability of workers and teams to have more ownership and accountability Leadership level 1. We hold back because of budget or staffing constraints and lack of leadership support 2. We give mixed messages Middle management 1. Middle management may level have to obstruct upper leadership goals for shared governance 2. Managers may feel threatened by having staff involved Frontline nurses level 1. There are those who Bthink I can”t[ and choose to think empowering themselves is someone else”s job 2. Some just hear about it and never Bget it[ were asked how leaders can best: (1) Bdetermine the empowerment needs of staff,[ (2) Bembed and reinforce empowerment among the system”s workers,[ and (3) Bensure leadership accountability for worker empowerment.[ We reviewed leadership philosophy compared with what the leaders believe the workforce actually experiences. Here we focus on how leaders reported they can best determine the empowerment needs of staff; a subsequent article will examine strategies for embedding empowerment and ensuing leadership accountability. From the 22 suggestions for determining staff”s needs, thematic analysis identified 6 distinct techniques.13 In round 3, participants from round 2 rated these 6 techniques for determining staff needs for empowerment as to their likely ease of implementation and their likely impact or effectiveness. Table 2 lists the techniques that resulted from identifying empowerment needs of staff from round 2. Techniques are sorted from high to low by ease of implementation based on panel members” ratings in round 3. Higher ratings reflect greater ease of implementation and greater expected impact. Combining these 2 ratings permits identification of the C-suite executives” top 3 rated techniques for empowering the workforce, as shown at the bottom of Table 2. Note that some easier techniques might be expected to have little impact, whereas other relatively easy techniques may have a major impact and that some difficult-to-implement techniques may produce greater impact. Overall Observation: Current State Versus Desired State Participation in this study may have alerted the Csuite to a need to take less for granted in relation to empowerment and to find appropriate ways to be more proactive in fostering empowerment.14 Table 3 summarizes the C-suite”s current and optimal philosophies for empowerment after reviewing the iterative Delphi process. While supporting workforce empowerment, the leaders perceived their roles as largely passive when characterizing the barriers to empowerment in round 1. However, they also recognized that advancing workforce empowerment would require a much more active engagement on their part. The Delphi panel process we used helped the C-suite gain a collective view of needed action to support empowerment without removing empowerment from the workforce. Discussion This article illustrates a methodology that can raise awareness of the role of C-suite leaders in supporting the department of nursing and others in fostering shared governance and thus empowerment. Through the iterative process of the Delphi panel process, the JONA Vol. 48, No. 7/8 July/August 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. 397 Table 2. Techniques Suggested by C-Suite Members to Identify Empowerment Needs of the Workforce Easy to Degree of Implement Impact Techniques for Identifying Workforce Empowerment Needs 3.87 3.53 Communicate regularly through staff meetings and town hall sessions 3.80 4.00 Conduct rounds with staff at the unit level, asking questions to identify issues and gather staff input 3.73 3.67 Consistently ask subordinate managers and staff to recommend solutions to workplace and performance issues 3.73 3.40 Conduct small group discussions with leaders at different levels of the organization 3.64 3.86 Create direct ties to unit managers and staff 3.20 4.27 Encourage employees to become problem solvers for patients, patient safety, and quality patient care Top 3 Techniques, Combining Ease and Impact Ratings 7.80 Conduct rounds with staff at the unit level, asking questions to identify issues and gather staff input 7.50 Create direct ties to unit managers and staff 7.47 Encourage employees to become problem solvers for patients, patient safety, and quality patient care C-suite members explored their philosophy of empowerment and ways to learn more about what the workforce needs for empowerment and became aware of inconsistencies in their current actions in support of shared governance and empowerment. C-suite members have a direct and significant effect on their company”s performance. Therefore, their buy-in, ideology, and actions are critical.15,16 Implications for Nursing Administration Shared governance and true employee empowerment are most effectively implemented when established through a joint effort between the administration/managers and staff.3,4 By working collaboratively, shared governance can be implemented in a manner that both creates a work environment where frontline employees can empower themselves and demonstrates leadership”s active efforts to improve professional nursing practice. This study reinforces the critical role of C-suite leaders, including the CNE, in supporting empowerment.17 Such efforts are clearly in alignment with the American Organization of Nurse Executives” nurse executive competencies, which recommends communication, and relationship management competencies.18 Table 3. C-Suite Orientation to Barriers and Strategies for Empowerment, Comparing Then-Current State to Desired State Round 1: Barriers to Empowerment (Then-Current State) Constructive Passive Aggressive Undetermined 10% 75% 10% 0% Round 2: Strategies to Empower (Desired State) Constructive Passive Aggressive Undetermined 76% 24% 0% 0% Implications for C-Suite Executives Organizational leaders, especially at the executive C-suite level should assess the current state of shared governance and empowerment to determine a baseline for action planning. An essential step in this assessment should be a review of the current philosophy, roles, and actions of C-suite leaders in supporting empowerment. If a culture of empowerment has not been well established, executive leaders may wish to seek coaching about how actively to identify and adopt best practice techniques for learning from staff about their needs for advancing empowerment, as illustrated in Table 2. Increasing visibility and communicating exemplars of employee empowerment may help foster a more empowering culture. Celebrating successes and monitoring the effectiveness of teams through identified management indicators are also key. One way to regularly check the pulse of strategies may be for specific C-suite executives to take turns rounding with 1 or 2 shared governance practice councils to hear what local teams are planning and doing. The 1st steps are for the C-suite executives and their direct reports to check in on their collective understandings about workforce empowerment and how they can learn more about their staff”s empowerment needs. During self-assessment, determination of phasing, implementation, and maintenance of appropriate types of empowering actions, the C-suite should focus on increasing their own personal awareness of the practices and behaviors that may best support empowerment and shared governance effectiveness in their organization or department. Leaders will be better positioned if they develop and maintain, on an ongoing basis, awareness of the environmental resources and support that are needed by subordinates and frontline employees. JONA Vol. 48, No. 7/8 July/August 2018 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. 398 Limitations This study was conducted in a single 8-hospital healthcare system of 2400 total beds. Although these methods may be useful in many settings, the specific results may be different in other settings. There were variations in leadership styles and the effectiveness of empowerment structures across teams and departments that could not be detected by the methods described here. The results presented here derive from a systematic 3-round Delphi process that solicited C-suite comments and suggestions; the self-reported observations were not validated by other methods in the conduct of this study. Conclusion This study used a Delphi panel approach to examine leadership”s empowerment philosophy in 1 system and to identify the easiest and most effective steps for actively promoting shared governance and empowerment. Initially, the C-suite executives did not recognize that they have an active role in fostering empowerment. Results reported here revealed that leadership supported empowerment, recognized their passivity as a potential barrier, and were able and willing to identify best practices, in their context, for learning more from their workforce about staff needs for empowerment. Before organizations embark on implementing shared governance or improving workforce empowerment, an assessment of organizational readiness is recommended. This assessment should give leadership the opportunity to assess their current competencies and opportunities for improving their capacity in support of workforce empowerment or shared governance. Organizations may find and sustain a steady course of continuous improvement if they periodically 1) examine the current state of empowerment in the organization, 2) clarify their empowerment philosophy and best techniques for fostering empowerment, and 3) adopt practical steps for fostering empowerment and evaluate the results on an ongoing basis. Acknowledgments The authors thank Dr Janet Williams, Dr Diane Huber, Ms Donna Shaver, the American Organization of Nurse Executives, Winter Park Health Foundation and Mr Bill Donahue. References 1. Flor R. Organizational development readiness: six conditions. Paper presented at the Capella University Residency; December 2, 2005; Minneapolis, Minnesota. 2. Schein E. Organizational Culture and Leadership. San Francisco, CA: Jossey-Bass; 2010. 3. Kanter RM. Men and Women of the Corporation. New York, NY: Basic Books; 1997. 4. Sieloff CL. Measuring nursing power within organizations. Nurs Scholarsh. 2003;35(2):183-187. 5. Sieloff CL, Bularzik AM. Group power through the lens of the 21st century and beyond: further validation of the SieloffKing assessment of group power within organizations. J Nurs Manag. 2011;19(8):1020-1027. 6. Sieloff CL. Development of a Theory of Departmental Power in Advancing King”s Systems Framework and Theory of Goal Attainment. Thousand Oaks, CA: Sage Publications; 1995. 7. Bogue RJ, Joseph ML, Sieloff CL. Shared governance as vertical alignment of nursing group power and nurse practice council effectiveness. J Nurs Manag. 2009;17(1):4-14. 8. Joseph ML, Bogue RJ. A theory-based approach to nursing shared governance. Nurs Outlook. 2016;64(4):339-351. 9. Kathuria R, Joshi MP, Porth SJ. Organizational alignment and performance: past, present, and future. J Manage Decis. 2007;45(3):503-517. 10. Institute of Medicine of the National Academies. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011. 11. Dalkey N, Helmer O. An experimental application of the Delphi method to the use of experts. Manage Sci. 1963;9(3):458-467. 12. Helmer-Hirschberg O. Analysis of the Future: The Delphi Method. Santa Monica, CA: The RAND Corporation; 1967. 13. Braun V, Clarke V. Using thematic analysis in psychology. J Qual Res Psychol. 2006;3(2):77-101. 14. Cooke RA, Lafferty JC. Organizational Culture InventoryA. Human SynergisticsA International; 2002. http://humansynergistics

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