Who’s ‘the Hospital’? Shared Governance Requires Transparent Organizational Decision-Making

When ‘the hospital’ speaks as a single, unified entity.

Many nurses working in hospitals do not know the decision-makers who affect their job. To patients, visitors, donors, accreditors, and other external constituents, hospital systems benefit from being personified as a single, unilateral-appearing brand.

However, when a decision is said to have been made by ‘the hospital,’ rather than by a specific person in the hospital, such language obscures who made the decision and why it was made. Lack of transparency around decision-making processes may be one reason some nurses feel shared governance models are more ‘lip service’ than genuine shared decision-making.

A common health care structure is a large system in which one main ‘flagship’ hospital serves as a central hub, with smaller branch hospitals/clinics with the same name and branding serving patients in other locations that may not be able to support a large hospital or multiple medical specialties.

For example, imagine a 20-bed rural hospital that is affiliated with Higher Education University, a hospital system with their main urban campus in a city one-hour away. The rural hospital’s affiliation with Higher Education University’s hospital system is important for external constituents. A patient may perceive that they do not have to travel an hour to receive top-quality care; a Higher Education University branch exists just minutes from their home and is perceived to offer the same level and quality of care. Moreover, if that patient cannot be treated in the rural location, they can be transferred to the main campus hospital. In this way, the reputation of Higher Education University is shared among both the urban and rural communities and is enhanced by the reputation of the flagship hospital.

Lack of clarity about where decisions originate.

Imagine you are an RN with almost a decade of bedside experience. You worked at the main campus hospital, but then moved to the rural city and discovered that this rural branch operates very differently from the main campus. You find that your current rural workplace doesn’t live up to expectations based on external institutional reputation, with decisions that affect your job in your new workplace originating with the main health campus administration. Often, you find that administrative decisions are depersonalized such that the decision-maker is pseudonymously referred to as Higher Education University.

However, a corporate entity is not autonomous; a person or persons made the decision. While that person may have had legitimate reasons for the decisions they made on behalf of the institution, their depersonalization from the decision made often means they are not available for feedback or accountable to those tasked with implementing their decision. Depersonalized decision-making may leave staff feeling excluded, unimportant, and powerless to participate in institutional decision-making.

Layers of distance from the actual decision.

While main campus staff may have organically met these decision-makers at least in passing or can directly seek out these decision-makers more easily, staff at other locations may not have that same opportunity. In some cases, even main campus staff may be excluded from participating in institutional decision-making because of the depersonalized nature of many decision-making processes.

Improving transparency.

Hospital systems can alleviate these differing expectations to internal constituents through shared governance and decision-making. Interventions to improve decision-making transparency can include providing open access to documentation of who has made decisions and clear descriptions of their rationale.

Transparent decisions can benefit organizations because frustration or resistance to change may be derived from lack of accountability. Decision-making transparency is particularly important to shared governance models. Shared decision-making relies upon all parties having transparent access to information. Additionally, employees experience frustration or feel cynical when decisions are made that contradict employee recommendations.

The limits of some shared governance models.

Shared decision-making models purport to be the opposite of opaque, hierarchical models of decision-making. However, a health care organization with a shared governance model but without transparent decision-making may be perceived by employees as no different from the top-down model. De-personifying the health care organization as a decision-making entity and restoring accessibility and accountability to decision-makers may reduce the employee frustration and cynicism that often surround workplace changes.

What can nurses do?

• Prompt a bottom-up approach by asking for sources of decision-making to be clarified and transparent.
• Offer respectful feedback to decision-makers to support a two-way communication channel.
• Attend board meetings to provide decision-makers with perspective from nurse-related organization constituents.
• Model shared governance within unit decisions through committee participation and unit nursing councils.

Jacqueline Christianson, PhD, FNP-C, is an assistant professor in the Marquette University College of Nursing whose program of research centers around improving workplace well-being among healthcare professionals. Their academic work is informed by ongoing clinical practice as a locum tenens (travel) nurse practitioner in emergency departments and intensive care units.

Natalie Schneider, PhD, MBA, is a clinical assistant professor at Purdue University in organizational behavior and human resources. Her research examines how employees and organizations can build and develop resources to contend with severe work stressors such as workplace sexual, gender, and racial harassment, particularly within the health care industry.