Shared Decision-Making in 2012

Shared Governance – A Meeting to Attend or a Philosophy of Practice Ownership to Live?

Nursing practice is impacted and guided by a multitude of sources ranging from regulatory guidelines and professional/workplace standards to best practice and research. Further influencing nursing practice are each of our individual skill sets and experiences. Catawba Valley Medical Center’s organizational policies and procedures are designed to outline desired clinical nursing practice; therefore, educate our day-to-day practice. Shared Governance (SG) is the link between all of these factors impacting practice and the care we render to our patients every day. 

SG serves as the framework for encouraging collaboration and shared decision-making between clinical experts, nurses at the bedside and management. Specifically, SG supports clinical nurses’ participation in decision-making regarding practice and quality at CVMC. It is this partnership of clinical and managerial expertise that makes us the unique healthcare organization that we are!

CVMC’s SG structure recognizes participation from all professional nursing staff members and demonstrates shared decision making within the formal structure of nursing. All council decisions are made utilizing the consensus seeking model to foster inclusiveness, participation, and professional exchange of the council membership.

The SG model at CVMC is comprised of a Nurse Practice Council (NPC) and individual Unit-Based Councils (UBC’s). Each UBC and the NPC have a defined mission, purpose and set of charters. The UBCs have a reporting relationship with the NPC, which is comprised of the chairpersons or designee of the UBCs, several leadership councils, and the Senior VP of Nursing and Patient Care Service. The NPC is responsible for coordinating the activities of all the UBC’s, resulting in consistent shared decision-making throughout the organization’s patient care departments.

Why get involved in SG?

  • Prime opportunity to influence the quality of care you and others provide.
  • Actively participating in SG is an opportunity to develop career-building skills in practice, research, quality, education, and leadership.
  • Rather than being one who reacts to change initiated by others, you can become a partner in the process.
  • Serving as a UBC member, possibly even chairperson is a recognized leadership role within CVMC.
  • The ability to lead and influence others is a necessary step in advancing your own professional development as well as that of nursing at large.

For more information about Shared Governance or opportunities to be involved, speak with any of your unit based council representatives, the NPC Chair (Debbie Martin,or your nurse manager.

Reflection of the Year Past

During the calendar year 2012, the NPC concentrated on devising a formal set of standards and expectations for nursing at CVMC along with an education and dissemination plan. November 2012 marked the implementation of CVMC’s first official Nursing Bylaws. You can read more details about the CVMC Nursing Bylaws a separate article in “The Art of Nursing”.

The table below highlights some of the main activities and accomplishments attained by UBCs in 2012. The continued need to scroll is a testimony to vast activities taking place at CVMC! Furthermore, it demonstrates the level of ownership of CVMC nurses, particularly those involved in SG, on care-delivery!

Shared Governance Activities and Accomplishments during 2012

Work Area Activities & Accomplishments


(Chair: Janis Hardin)

  1. EBP: Performed a literature review on capnography use in PACU; Decision: trial usage for ortho patients and those with documented sleep apnea to improve patient outcome and prevent near misses of respiratory compromise.
  2. SG Promotion and Dissemination of activities: Placed shared governance minutes on healthstream to increase staff awareness of what SG is working on. In addition, Also SG agenda is shared electronically before each meeting to elicit input & suggestions.
  3. Patient Satisfaction: Process implemented to facilitate quick parental visitation with pediatric patients
  4. Patient & Nurse Satisfaction: Developed discharge education book to help with evening and weekend discharges
  5. Patient Satisfaction: Increase patient privacy by implementing privacy procedures: such as pulling curtains between patients when report is being given; and decreasing care giver volume while giving report and discussing patient information.
  6. Patient satisfaction: Developed and implemented protocol to increased frequency of updates to family members
  7. Clinical Quality: Developed Ofirmev Data Tool; data given to surgeons and anesthesiologist to increase usage

Oncology/Infusion Center

(Chair: Deanna Grieffie)


  1. Quality Care: Active Participant Pavilion Move; Workflow and education to prepare for the scheduled move in January 2013.
  2. Call for Excellence – Certification. Three newly oncology certified nurses.
  3. Patient Satisfaction: Currently planning a trial of grouping tasks and changing intervention timing to reduce interruptions for patients. Goal: Decreases noise & Increases rest. Pilot phase to begin in February 2013 for a 90-day period.
  4. Nurse Satisfaction: Added a suggestion box to both lounges with forms for staff to voice concerns or express ideas to improve our unit or our practice. (If you voice a concern, you have to offer an idea to resolve the problem.)
  5. Professional Organization Involvement: Two members of our staff attended National Congress for the Oncology Nursing Society 2012. Plan for 2013: two different staff member to attend National Congress for ONS in 2013.


(Chair: Chris Bowman)


  1. Patient Safety: The council has continued to monitor and evaluate Feeding Readiness in the premature infants, and help educate new RNs to this practice.
  2. Leading the Way – RN as Role Model: The committee has been encouraging other staff to stay positive during the move to the pavilion. The idea was to make a box that staff could write down suggestions, complaints, and compliments of the pavilion that could be focused on right after the move.
  3. Community Involvement: Toys for Tots, Vera Bradley fundraiser for the CVMC Help Fund.
  4. Nurse Satisfaction & Team Building: 2 softball games. Nursery RNs versus Nursery RTs


(Chair: Miriam Smith)


  1. Clinical/Quality Improvement: Piloted and implemented “real time” documentation for vital signs and intake and output data. 
  2. Patient Satisfaction: Implemented a ‘Noise Reduction Protocol’ containing several interventions by staff to maintain a calming and noise-free environment.
  3. Interdisciplinary Collaboration & Patient Satisfaction: Successfully partnered with the Hospitalist Physicians and the Pharmacy staff to create Routine Standing Orders for pain management with our Hospitalist patients to help improve patients’ experience and management of pain.
  4. Nurse Satisfaction and Team Building: Collaborated to design a Medical Unit T-shirt to promote group cohesion.


(Chair: Heather Lindsey)


  1. Clinical Quality – Ongoing Research Project. Development of Exercise Group: training of staff and implementation on unit
  2. Clinical Quality: Resource Guide Book for the unit. Development of a guide book for common issues on our floor for reference: describes in detail how to complete common processes, such as internal or external transfers, involuntary commitment paperwork, guardianship paperwork, etc.; Outlines the responsibilities of all the team members (nurses, MDs, social workers, and other team members).  
  3. Clinical Quality: Participation in Disseminating Unit Quality & Satisfaction Indicators. Shared governance group responsible for designing and maintaining bulletin board in break room for staff education (fall education, positive peer comments to highlight great care or teamwork given by our staff and highlighting newly hired employees on the unit.)
  4. Nurse Satisfaction: Implementation of 3p-11p ‘float nurse’ to assists with admissions and discharges as well as other unit needs. 3P – 11p was identified as a high volume and task intense time period, leading to this re-allocation of resources to promote patient safety, as well as patient and nurse satisfaction.
  5. Patient Satisfaction: Donation Drive and Reorganization of Donations Closet
  6. Patient Satisfaction: Reorganization of Patient Belongings closet on unit alphabetically instead of by room number to cut down on errors and belongings being left behind by patients on discharge.
  7. Patient Satisfaction: Development of new tagging system for patient belongings
  8. Patient Satisfaction: Ongoing Maintenance of library cart for patient use.
  9. Patient Satisfaction: Christmas treat bag donations and distribution (patients decorated the treat bags during groups in the weeks leading up to Christmas, then the shared governance council filled the treat bags with the staff donations and distributed them on Christmas morning.
  10. Patient Satisfaction: Guidebook to Psychiatry – translated into Spanish to accommodate the Spanish-speaking patients and families.

Surgical/Ortho/Inpatient Rehab/SC

(Chair: Casey Mueller, Cindy Rose)


  1. Quality & Patient Safety: Ongoing Research Project – NIZ = No Interruption Zone. Study examines the impact of a NIZ protocol on interruptions during medication administration.
    1. Pre-implementation data collection completed 
    2. Implementation of NIZ Protocol to begin early 2013 
    3. Post-data collection to start in early July 2013.

Birthing Center

(Chair: Julia Peters)

  1. Clinical Quality& Patient Satisfaction: Revision of the Postpartum Booklet to reduce paperwork, redundancy, and elimination of unnecessary information.
  2. Clinical Quality: PACU education
  3. Patient Satisfaction: Development of a ‘Take Home Box’ (containing mementoes) for the birth mom of babies given up for adoption.
  4. Efforts to increase nurse satisfaction with meal breaks. 
    1. Process to allow for uninterrupted break  
  5. Promotional activities to increase SG awareness and participation.
  6. Nurse Satisfaction: Design of unit t-shirts to promote unit cohesiveness. 


(Chair: Angela Herman)

  • information pending

Emergency Department

(Laurie Ramsey)

  1. Clinical Quality & Patient Satisfaction: Instituted bedside reporting.
  2. Clinical Quality & Patient Satisfaction: Developed and implemented patient communication boards. 
  3. Patient Satisfaction: VISINE Program to get the ‘red’ out on our patient trackers and improve patient throughput 
  4. Nurse Satisfaction: Bulletin Boards to celebrate staff accomplishments
  5. Nurse Satisfaction: Collaborated with leadership to develop and implement work schedules that reduce required weekends from three weekend is a six weeks schedule to two weekends.
  6. Community: Ongoing backpack for kids program that sends food home with kids for weekends and evenings that otherwise may not have access to food.
  7. Community: Bike safety event at a local church 

Day Surgery

(Chair: Kelly Ward)

  1. Patient Satisfaction: Designation of a primary rounding nurse, which has improved pt. satisfaction scores within the surgical suite.
  2. Nurse Satisfaction: Computers in day surgery cubicles to facilitate a more secluded setting while preparing papers related to discharge from day surgery.
  3. Clinical Indicator: Pre-op time study completed with the aim of evaluating the prep time needed to prepare pt’s for surgery. This time study resulted in the re-allocation of task to include using our NA’s to perform some duties such as giving enemas, shave preps, vital signs, etc.
  4. Clinical Indicator: Review of the literature related to sleep apnea resulted in changes to discharge instructions. Additions included “if using C-PAP at home, use your C-PAP when napping or sleeping that first day when getting home from surgery”.

Operting Room

(Chair: Lindsay Cox)

  1. Patient Satisfaction: 
    1. Implemented a process to decrease noise in the OR room at the beginning of the case (prior to anesthesia induction) as well as at the time of patients emerging from anesthesia.
    2. Improved communication related to delays. Press-Ganey scores improved to above Press Ganey mean and 75th percentile.
  2. Nurse satisfaction:  Evaluated responsibility of documenting day surgery tie out times which at the time was performed by the OR nurse. After a trial of process changes, determined that time was not needed so OR nurse no longer has to keep up with this additional time-out.
  3. Clinical indicator: Worked to decrease traffic in and out of the rooms to facilitate and promote a safe environment for the patient.  When traffic patterns are disturbed, particle counts increase.  Worked to get certain items outside each OR, such as phones with all frequently posted used numbers in the hallways, a standardized positioning cart, and a pillow cart.  Also ordered and installed DO NOT ENTER tapes on all OR rooms that were not on the core.

Radiology/Diagnostic Services

(Chair: Melissa Goad)

  • information pending

Nurse Practice Council (NPC Chair: Debbie Martin)


  • Authorship and Implementation (including education strategy) of CMVC’s first Nursing Bylaws.