SE - Structural Empowerment

SE1: Professional Engagement-Describe and demonstrate the structure(s) and process(es) that enable nurses from all settings and roles to actively participate in organizational decision-making groups such as committees, councils, and task forces.

Rita Smith DNP, RN Chief Nursing Officer (CNO), understands that critical thinking is a high-level cognitive process that includes creativity, problem-solving and decision making. The Shared Governance Process provides an avenue for nurses to actively participate in defining their practice. This process empowers nurses to make decisions about clinical practice standards, quality improvement, professional development and to pursue research activities. It enables nurses to assume full accountability for nursing practice while participating in collegial interdisciplinary relationships. Shared Governance supports an autonomous environment, providing nurses at all levels the opportunity to have professional control over their practice and extend their influence into administrative areas. Ms. Smith is aware that this process allows nurses to utilize their knowledge and expertise and to network with colleagues and collaborate among the units. The development of the organizational decision making groups provides an avenue for nurses to use critical thinking to develop a process of examining underlying assumptions, interpret and evaluate arguments, imagine and explore alternatives, and develop a reflective criticism for the purpose of reaching a conclusion that can be justified.

The organizational culture of JCMC and the magnet philosophy provides nurses the opportunity to collaborate with various disciplines ensuring the delivery of safe and quality care. Nurses at all levels are often invited to participate in many interdisciplinary initiatives and committees. Consequently, nurses are valuable members of more than twenty interdisciplinary task forces, committees, and nursing councils. The Chief Nursing Officer supports the nursing staff by providing the opportunity for all nurses to become active members of any council they wish. Ms. Smith uses her influence within the organization to insure flexibility with scheduling and financial support at all levels.

Senior leadership involvement in organizational decision making

Rita Smith RN, DNP, Chief Nursing Officer, is vital in conveying nursing goals and perspectives to organizational decision making. This is accomplished through her involvement in various organizational and executive senior leadership committees. In addition, Rita Smith holds a prestigious voting position on the Board of Trustees offering the opportunity to maintain nursing at the core of this governing body. Examples of Rita Smith’s involvements include:

  • Medical Executive Committee - a forum where hospital wide issues related to medical/physician practices are discussed and improvement strategies are identified
  • Quality Management Steering Council - establishes the framework for quality and improvement initiatives throughout the organization
  • Strategic Growth Council - addresses areas and service lines for growth and improvements.

A full list with detailed information regarding committees attended by Rita Smith is found on TL4 and Reference OO15-A.

Brenda Hall MS, RN, NE-BC, Senior Vice President of Safety, Quality, and Regulatory Affairs, coordinates a comprehensive system-wide patient safety program at Jersey City Medical Center. She is instrumental in promoting a culture of safety through shared decision making with nursing leaders. Various committees led by Brenda, provide nurses the opportunity to actively seek opportunities to minimize error and other preventable events. Brenda successfully provides a forum for nurses to provide input in developing effective safety strategies for monitoring, reporting, and improving safety-related activities. Examples of Interdisciplinary committees meeting led or participated by Brenda Hall include:

  • Pain Management Task Force - designs and improves the process of pain management and assessment
  • Patient Safety and Clinical Quality Council - a program outlining the requirements for monitoring and analyzing risk to patient safety
  • Ethics Committee - chaired by Brenda, provides guidance and support to patients and clinicians through ethics consultation, education, policy review and development.

For more information regarding committees attended or led by Brenda please refer to Reference OO15-A

Nurse Leaders involvement in organizational decision-making

Nursing Leaders at JCMC are integral parts of the decision making process. Our directors, nurse managers, clinical nurse leaders, advance practice nurses, PI specialists, and coordinators bring a variety of skills, expertise and knowledge to the decisions made at various task forces, and committees. Their voices at these meetings represent the best interest of the nursing staff and the patients they serve. Through shared decision making and collaboration with multidisciplinary teams, JCMC leaders share in complex responsibilities that directly affect the care that is provided to patients and their family members. Examples of nurse leadership involvement include:

  • Nurse Managers meeting – (attended by all in nursing management) to discuss, analyze and develop strategies that improve nursing practice on all units
  • Infection Control Committee – Developed/investigates strategies that assist in preventing infections hospital wide
  • Rapid Response/ Code Blue Task Force – analyzes data relational to rapid responses and code blue’s and establishes goals to improve patient outcomes

A complete list with detailed information regarding Interdisciplinary committees attended by our clinical leaders is found on Reference OO15-A

Interdisciplinary Structure for Shared Decision Making Groups

Nursing shared governance structure and process

Jersey City Medical Center embraces the Shared Governance structure as their professional nursing practice model. This model provides nurses with greater opportunities for decision-making and fosters accountability and autonomy in the delivery of efficient and effective patient care. It allows staff to play an active role in unit operations through shared power, control, autonomy, and influence. Nurses practicing at the bedside are offered the opportunity to execute clinical decisions pertaining to nursing practice regularly. Nurses at JCMC embrace the idea that shared governance is a necessity and a professional journey, offering them the opportunity to demonstrate influence and present a positive force through participation in unit practice councils (UPC), major nursing councils, and clinical ladder program. These councils allow for vertical and horizontal communication among staff nurses and nursing leaders.

Jersey City Medical Center: Shared Governance Model

Unit Practice Council (UPC)

The UPCs are unit specific councils available on each nursing unit. The councils are composed entirely of nursing staff and allow for decision making that are specific to each individual nursing units. Any member employed on that unit is given the opportunity to attend and participate during monthly meetings. The UPC provides a forum for staff nurses to discuss unit specific issues, initiatives, and suggest proactive solutions and evidence based interventions. Subjects such as hand offs, nurse and patient satisfactions scores, and quality performance improvement activities have been discussed at UPC meetings. A report from each of the four major nursing councils, are provided to the staff to ensure the group is updated and informed of hospital wide nursing initiatives.

Unit Practice Council Committee Example: Regina O’Donnell Clinical ladder III RN - Trending Compliance on the Cardiac Catheterization Checklist

The completion of the pre-cardiac catheterization checklist was a major concern brought to the monthly UPC meeting by the nurses working in the Cardiac Catheterization lab (CCL). The checklist is a tool available to nurses to ensure that all the appropriate information such as lab results, consent, etc are obtained prior to the procedure. Failure to complete this checklist can result in unnecessary delays and/or cancellations. In order to minimize and prevent this occurrence all the clinical ladder nurses working on that unit decided to randomly collect data regarding checklist completion between the months of January 1st though May 31, 2012.

SE1-Table 1

A monitoring tool was developed to help identify the selected areas on the checklist with missing information. The results of the data were analyzed and presented to the Professional Practice and Quality and Safety Councils. The objective of the presentation was to emphasize the importance of the checklist and to re-educate staff nurses to improve patient safety and quality of care by achieving 100% compliance on the pre cardiac catheterization checklist. Ongoing monitoring of compliance will continue to identify barriers and implement further improvement strategies as needed.

Data collected by Cardiac Catheterization Nurses

SE1-Table 2

SE1-Table 3

Hospital Wide UPC

The hospital Wide UPC meeting is held monthly to offer support to unit council chair member and to maintain consistency in structure throughout all units. For example when concerns regarding decision making and communication with nurse managers was expressed, a form was developed to facilitate the process and enhance communication between managers and UPC chairs, allowing decision making to occur seamlessly at the staff level. For more information please refer to the attached UPC meeting minutes (Appendix SE1-A)

Major Nursing Councils

Nurses from all nursing units have the opportunity to join one of the four major nursing councils. These councils address issues and make decisions that impact more than one unit or other departments. These forums empower nurses to implement practice standards, design quality improvement strategies, improve nursing satisfaction, and pursue research activities. Through these councils, action plans are developed that encompasses evidence based practice, clinical expertise, and quality of care. All Nurses participating in these councils abide by the shared governance bylaws (Reference SE1-A).

The four major councils at JCMC include

  • Professional Practice
  • Quality and Safety
  • Nursing Research
  • Staff Retention
  • Staff Retention and Satisfaction

Regina O’Donnell RN, BSN, CCRN Chairperson of Professional Practice Council 2011
 Regina O’Donnell RN, BSN, CCRN Chairperson of Professional Practice Council 2011  

Professional Practice Council: Provides nurses the ability to make decision regarding nursing processes, policies, forms, etc which impacts more than one unit or department. Approval by this council is required, prior to implementation, for any process or policy change impacting nursing and patient care.

Many recommendations and practice changes have been implemented due to nurse involvement in the professional practice council. For example when a staff nurse reported that tube shortages from the pneumatic system caused her to spend excess time looking for them, keeping her away from her patients, it was this council that recommended for an increase in the PAR level. Extra tubes were ordered, labeled and distributed to each unit based on usage. This is a simple example of a small change that had a huge impact on nursing.

Call Bell Standards of Behavior

Quality and Safety: Provides a forum for nursing initiative and performance improvement strategies to be reported by staff nurses. Any nursing process such as policy revisions that impact quality and patient outcomes are reviewed and optimized by this committee. Educations regarding safe practices are provided to committee member who bring back the information to the units through their UPCs.

In early 2011, a staff nurses brought forth to the committee the suggestion “Everyone should answer the call bell” Based on her suggestion the call bell standards were posted and reinforced during UPC meeting. This was instrumental in reinforcing JCMC’s culture of providing “Patient Centered Family Focused” care.

Rosanna Vales BSN, RN Member of Nursing Research Council Since 2010
 Rosanna Vales BSN, RN Member of Nursing Research Council Since 2010 

Nursing Research: This committee serves as a resource to staff in providing education, ensuring availability of resources at the point of care, designing and implementing nursing research studies, and collaborating on joint research projects.

Rosanna Vales as long standing member of the research council states, "Participation in the Research Council has sharpened my critical thinking skills. Honing in on what can be improved in ordinary mundane-like practices made me thirst for out-of-the-box "what if" questions. With the prodding and big hand from the Research Council, questions can be explored in evidenced-based protocol at the point-of-care using the Nurse Reference Center."


Staff Retention and Satisfaction: This council works diligently in identifying staff needs, monitoring nursing and physician satisfaction and implementing action plans.

One of the major accomplishments of the Staff Retention and Satisfaction is the roll out of the NDNQI survey each year. Most importantly the council designed a process for each unit to evaluate the survey results and provide feed back through their individual UPCs. An action plan is devised each year using the staff nurses input and suggestions.

The staff Retention and Satisfaction council is also instrumental in planning the fun filled activities for Nurse’s week. In 2011 the nurses participated in planting a tree on the Jersey City Medical Center Campus. This activity betokened the theme “Nurses Entrusted to Care for the Earth”. For a flyer of the event please refer to (Appendix SE1-B)

Clinical Ladder Program

Nurses have the opportunity to become involved in organizational decision making through involvement in the clinical ladder program. The goal of this program is to recognize and reward professional nurses who develop clinical excellence, encourage professional growth, provide exceptional patient care, enhance recruitment and retention of nurses, and improve patient satisfaction, through organizational involvement and shared decision making. This differential practice program is based on the research of Patricia Benner PhD, RN. Benner’s classic work “From Novice to Expert (1984)” describes five attributes of professional nurses as they gain experience and education.

  • Novice (Clinical Ladder level I)
  • Advanced Beginner (Clinical Ladder level I)
  • Competent (Clinical Ladder level II)
  • Proficient (Clinical Ladder level II)
  • Expert (Clinical Ladder level III)
  • Clinical Nurse Leader (Clinical Ladder level IV non exempt employee)

Nurses can choose to apply for any level based on their level of expertise and ability to meet eligibility criteria. To achieve clinical ladder status, a clinical ladder portfolio is developed and presented, to the staff led clinical ladder committee, with supporting documentation of five areas of excellence which include:

  • Nursing Leadership
  • Professional development
  • Research and evidence based practice
  • Community involvement
  • Clinical Expertise

Other requirements for all levels include joining a council/committee and implementing a clinical project with well designed strategies, objectives, and measurable goals. For a complete listing of Clinical Projects please refer to (Appendix SE1-C)

Clinical Ladder Project Examples:

Project title: An Hour Glass Framework to Prevent and Control Infections

Senen Cabalfin BSN, RN, Clinical Ladder III, is a staff nurse in the OR, identified a need to educate patients and the community on reducing surgical site infections. She decided to implement a project titled “An hour glass” framework to prevent and control infections. Using the hourglass model the first phase of this project is to educate community members regarding proper hygiene practices to reduce community acquired infection. The second phase of this project is to implement a process for the nursing staff to educate preoperative patients of JCMC on proper skin preparation using CHG soap, prior to their surgery. Her goal is to reduce surgical site infections by 75% with the use of industrial partner products pre-operatively for 12 months. She is tracking her progress through data collection and monitoring.

Project title: On the Cusp: Stop CAUTI

Yvette Bryant RN, MSN, Clinical Ladder III, staff nurse in 7W medical surgical unit, identified a need to reinforce the CAUTI bundles with nursing and medical staff. Using the CUSP methodology, she decided to implement and reinforce the CAUTI bundles on her unit. She elicits a change in practice by assessing the necessity of urinary catheters daily on all patients in her unit. She provides ongoing education to the nurses and patient care technicians on urinary catheter care and maintenance. She identifies barriers and implements strategies to eliminate or reduce them. She is instrumental in motivating staff by encouraging and reinforcing bundle compliance during daily rounds and shift handoff.

Project title: Emergency Management of Shoulder Dystocia

Vivian Chang RN, BSN, Clinical Ladder III, a staff nurse in the labor and delivery unit, identified a need to improve emergency management of shoulder dystocia, to assure patient safety and enhance clinical quality and staff satisfaction. She decided to develop educational material and share it with her colleagues in the Labor and Delivery Unit. She also provided educational sessions to her nursing staff. She plans to assess staff improvement and evaluate clinical outcomes moving forward. She plans to create a PI tracking tool to monitor compliance of improvement strategies. Re-education of nursing staff will continue as necessary.

Adverse Events Team /Root Cause Analysis

Another process available for nurses from all levels to participate in the decision-making is the adverse events team.

SE1-Table 4

The team evaluates adverse events as they occur and offer support to staff nurses during the process. The adverse events team utilizes the root cause analysis method to evaluate all adverse events at JCMC. This is done on the premise that all events are opportunities for improvement. This method allows the team to focus on the true causes, such as system errors or process breakdown, which led to the event. A systematic approach is used allowing those involved the opportunity to describe why and how the incident occurred. This non-punitive forum assists those involved in designing or improving the process to prevent further reoccurrence of the problem. All members of the interdisciplinary team involved play an active role in the decision making process that leads to improving quality and safety at JCMC. For more information on the adverse events team please refer to OO25

Nursing participation during root cause analysis has led to the development of process and policy changes such as:

  • Improved handoff process between emergency room and critical care nurses
  • Revision of the double check policy to prevent medication errors
  • Updated the fecal management system (flexiseal) policy to reflect best practice with additional safety measure. For more information on this policy please refer to NK6.