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DOI: 10.1177/1744987120905620
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clinical nursing excellence
Omar Khraisat
Assistant Professor, Faculty of Nursing, Al-Ahliyya Amman University, Amman, Jordan

Khetam Al-awamreh
Associate Professor, Nursing College, AL-al Bayt University, Jordan

Mahmoud Hamdan
Director of Clinical Governance, King Saud Medical City Nursing Department, Kingdom of Saudi Arabia

Mohammed AL-Bashtawy
Professor, Nursing College, AL-al Bayt University, Jordan

Abdullah Al khawaldeh
Associate Professor, Nursing College, Jerash University, Jordan

Mohammad Alqudah
Clinical Instructor, Nursing College, Jerash University, Jordan

Jamal A. S. Qaddumi
Assistant Professor, An-Najah National University-Faculty of Medicine and Health Sciences, Nablus,
Palestine

Samer Haliq
Lecturer, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Saudi Arabia

Abstract
Background: Shared governance is examined through a framework for developing independent
decision making in professional nursing practice and improving patient care outcomes.
Aims: This study is designed to obtain a baseline measurement of the degree of shared
governance in a selected children’s hospital in Saudi Arabia.
Methods: The study was guided by the Donabedian model. The Professional Nursing
Governance Index was used. A total of 400 questionnaires were distributed to nurses working

Corresponding author:
Omar Khraisat, Faculty of Nursing, Al-Ahliyya Amman University, P.O. Box 19328 Amman, Jordan.
Email: khraisat1111@hotmail.com
2 Journal of Research in Nursing 0(0)

at the hospital, with a response rate of 77% (n ¼ 307). Descriptive and inferential statistics were
used for analysis.
Results: The results corresponded with those from nurses and managers in most subscales of
the Index of Professional Nursing Governance (information, goals, resources, participation and
practice). However, nurses working in the operating theatre and surgical unit have a perceived
higher level of shared governance than those in critical care units and medical wards.
Conclusions: The results could encourage shareholders and leaders in the nursing field to
develop the perception of shared governance by adopting a shared governance model, which
in turn might improve the quality of nursing care.

Keywords
children, governance, nursing, shared

Introduction
Shared governance is represented by a structural model that enables nurses to have control
over their practice (Alrwaihi et al., 2018; Lamoureux et al., 2014). Anthony (2004) and
Overcash et al. (2012) argued that shared governance is a model where a group of
associates direct, govern and regulate work through goal-oriented efforts in their organisation.
Applying a shared governance framework is claimed to improve the provision of good-
quality care (Alrwaihi et al., 2018, Barden et al., 2011). This develops collaborative
relationships between healthcare professionals, improving quality of care and overall
clinical effectiveness; it increases staff confidence; supports professional skills; raises
professional profiles; leads to improved communication; builds on original knowledge and
skills; improves professionalism and accountability; increases direction and focus; and
reduces duplication of effort to achieve excellence in Nursing (Barden et al., 2011;
Overcash et al., 2012).
Excellence is the dynamic process that integrates the best theoretical and practice
knowledge in each patient encounter. Nursing excellence was further associated with
outstanding results in patient satisfaction and nurse retention, where shared governance
was the vehicle used to integrate the excellence standards of Magnet accreditation to
achieve optimal health outcomes for the patient, nurses and system (Van Oyen, 2004).

Literature review
Shared governance was seen as a way of introducing empowerment and building structures
for funding it (Alrwaihi et al., 2018; Powers and Bacon, 2106). It is applied as a management
process model that authorizes and encourages the engagement of nursing staff in decision
making, with the purpose of improving their professional practice (Prince, 1997).
A shared governance model for nursing has long been recognised as an effective
leadership approach for improving the working environment by supporting nurses in
having greater autonomy and responsibility for the regulation of their work and practice
(Alrwaihi et al., 2018; Porter-O’Grady, 2001).
Nurses should be involved in decision making affecting their professionalism, allowing them
to be involved in controlling work issues, schedules and reviews – currently the province of
Khraisat et al. 3

managers (Barden et al., 2011; Powers and Bacon, 2106). Shared governance embraces four
principles: partnership, accountability, equity and ownership (Porter-O’Grady, 2001). It may
be structured using different models, including unit-based governance, which generally refers
to governance derived from a nursing unit; councillor governance, which refers to decisions
made by hospital-wide councils of nurses; administrative governance, which considers
executive rule as leadership intended for smaller nursing councils; and congressional
governance, which considers that all nursing staff work to form cabinets responsible for
controlling training (Alrwaihi et al., 2018; Anthony, 2004; Overcash et al., 2012; Porter-
O’Grady, 2001). These models have been reported to increase professional nurses’
contribution to operational practice and policy making, as well as demonstrating their
responsibility in the expansion of work schedules (Bretschneider et al., 2010).
Barden et al. (2011), Alrwaihi et al. (2018), and Joseph and Bogue (2016) argued that
shared governance can be considered as a framework or a system that supports and
empowers nurses in their workplace, and as a managerial structure that facilitates staff
members in making clinical decisions, thus increasing their satisfaction. As a result,
shared governance implementation leads to a satisfactory working environment for nurses
(Overcash et al., 2012; Powers and Bacon, 2106).
Shared governance gives nurses control over their professional practice, providing
structure and context for healthcare delivery (Mahmoud, 2016). This in turn can improve
the rate of patients’ satisfaction and strengthen nurses’ authority (Barden et al., 2011). The
model of professionally shared governance affects the quality of care positively through the
structure it provides (Bumgarner and Beard, 2003; Kramer et al., 2009; Hess, 2011;
Laschinger et al., 2003; Overcash et al., 2012; Powers and Bacon, 2106).
The outcomes of shared governance are difficult to measure, including whether or not the
practice is truly in place within an organisation (Porter-O’Grady, 2001). The governance
structure is required to ensure that the principles of shared decision making are boosted, but
structure alone is not considered shared governance (Anderson, 2011). According to
Anderson, ‘‘the concept is more than a structure; the philosophy of professional
accountability must be implemented’’ (Anderson, 2011: 198); hence, the measure of
governance is critical in evaluating outcomes and assessing the level of implementation.
Studying nursing concepts systematically to be suitable for implementation is a
prerequisite to promoting professional nursing practice (Joseph and Bogue, 2016).
In Saudi Arabia, limited evidence exists to assess shared governance in nursing,
specifically for children and young people’s services. This study aimed to obtain a baseline
measurement of the shared governance level in a selected children and young people’s
hospital in Riyadh, the capital of Saudi Arabia. The specific aims were to:

. Assess the level of shared governance in a children and young people’s hospital.
. Examine the differences of shared governance level among nurses in a children and young
people’s hospital.

Methods
Design
A descriptive study design was used. This study was conducted within a traditional
leadership environment where decisions were made commonly by managers, and shared
4 Journal of Research in Nursing 0(0)

governance councils were yet to be implemented. This work focussed on assessing the
current status of an empowerment structure as a prerequisite of the American
Nurses Credentialing Center (ANCC) Magnet Recognition Program in the hospital.
Data were collected using a self-report questionnaire from nursing staff and managers in
different units, including medical, surgical, critical care and the operating theatre, in the
largest public children’s hospital in Riyadh. The selected hospital is a 300-bed capacity
facility, providing both in- and outpatient haematology/oncology services to children.
Prior to data collection, Institutional Review Board approval was obtained from the
selected hospital.
Potential participants were approached in person by researchers and invited to complete
the study survey in a private room away from the clinical area. Following agreement from
the senior nursing leadership, the questionnaire was distributed during the last hour of the
working shift. Participants and their units were selected randomly from the list of names
provided by the nursing administration in the hospital. Participants were informed about the
purposes of the study. They were provided with the questionnaire along with a cover letter
explaining the purposes of the study.
The participants had full disclosure about the risks and benefits of the study. They were
also assured that participation was voluntary and they could withdraw from the study at any
time without any penalty (for example, it would not affect their performance evaluation in
the hospital). In addition, they were assured that all the information obtained would be
anonymised by assigning numbers to each participant’s questionnaire, keeping it in a locked
location and deleting the data completely once the study was concluded. Questionnaires were
completed and returned at the end of the working shift. Data were collected from August
2018 to October 2018.

Sample and setting

The target population of this study included all nurses currently employed in the selected
hospital (n ¼ 400) and able to understand written English. The estimated sample size was
calculated using the Power Primer (Cohen, 1992). The test revealed that, using a desired
power of 0.80, medium effect size (r ¼ 0.25) and 0.05 level of significance, the estimated
sample size was 250 nurses; over-sampling was targetted to account for attrition rate.
A convenience sample of the 307 of 400 nurses filled out and returned the self-
reporting questionnaire, with a response rate of 76.8%, which included their demographic
profile. Participant selection aimed to enhance the heterogeneity of the respondents,
recognising that nurses were represented by different cultural, and socio-economic
backgrounds.
The inclusion criteria comprised all nurses who are working in hospital units including
not limited to (for example) medical, surgical, critical care and the operating theatre, and
who understand the English language.

Measurements
Data were collected using the Index of Professional Nursing Governance (IPNG) developed
by Hess (1998). The IPNG was established to ‘‘measure the distribution of control, influence,
power, and authority’’ (Hess, 2011: 236). It produces an overall score of governance for
organisations, in addition to measuring readiness through an aggregate score for individual
Khraisat et al. 5

levels of management, units and departments (Hess, 2011). The IPNG was designed to rank
organisational professional governance as traditional governance, shared governance or self-
governance. According to Hess, organisations implementing shared governance should
achieve a minimum total score of 173.
The IPNG comprises 86 questions measuring levels of reported governance among
healthcare personnel on a scale from traditional, to shared and self-governance. The
scores are founded on a 5-point Likert-like response scale: 1 ¼ nursing management/
administration only; 2 ¼ primarily nursing management/administration with some staff
nurse input; 3 ¼ equally shared by staff nurses and nursing management/administration;
4 ¼ primarily staff nurses with some nursing management/administration; and 5 ¼ staff
nurses only. Scores 1 and 2 indicate decision making dominated by management/
administration, and 4 and 5 indicate more staff nurse participation in decision making.
The IPNG range of total scores reflecting a traditional, hierarchical decision-making
environment is 86–172. An environment of decision making shared by nurses at different
management levels would have an IPNG range of 173–344. If nurses are the decision-making
group, then the IPNG score range would be 345–430.
The six subscales of the index are: (1) nursing personnel, with 22 items assessing
who controls the personnel, and their structures; (2) information, of 15 items related to
who has access to the information connected to governance activities; (3) resources, of
13 items related to who influences practice; (4) participation, of 12 items related to who
contributes to structures connected to governance activities at different structural levels;
(5) practice, of 16 items assessing who controls proficient practice; and (6) goals, of
8 items related to who sets and negotiates the resolution of conflict at different
organizational levels.

Reliability and validity of the Index of Professional Nursing Governance

A total of 40 nurses participated in a pilot study to check for understanding, clarity and the
time required for completing the questionnaire. The Donabedian (1988) model was used to
guide the development of the instrument. This provides a framework for examining
healthcare services, assessing their quality in three categories: structure, process and
outcomes. Structure includes location, hospital buildings, staff, finance and equipment.
Process shows the relationship between patients and providers throughout the delivery of
healthcare. Finally, outcomes refer to the healthcare properties and effect on the health
status (Donabedian, 1988).
The pilot study was conducted in three departments of the hospital. A list was obtained
from the hospital departments, then for each clinical ward/unit, the questionnaire was
distributed according to the number of nurses. The Cronbach’s coefficient alpha for the
IPNG scale was 0.90.

Data analysis
The Statistical Package for the Social Sciences (SPSS) (version 17.0) was used for analysis.
Data were screened, and no missing values or outliers were found. Data were suitable for
descriptive and inferential statistics. To lower the risk of a type I error, the statistical
significance level was accepted at p < 0.05. In addition, the risk of a type II error was
lowered by increasing the sample size and using a power of 0.80.
6 Journal of Research in Nursing 0(0)

Table 1. Sociodemographic data of participants (n ¼ 307).

Variable No. %

Gender
Male 10 3.3
Female 297 96.7
Education level
Diploma 77 25.1
Baccalaureate 203 66.1
Master 27 8.8
Management position
Nurse staff 225 73.3
Nurse manager 82 26.7
Working units
Medical 89 29
Surgical 90 29.3
Critical Care 83 27
Operating Theatre 45 14.7

Results
The sample was predominantly female (96.7%, n ¼ 297). Two-thirds of the participants
(66.1%, n ¼ 203) were educated to baccalaureate level and the majority held the position
of staff nurse (73.3%, n ¼ 225) (see Table 1).

IPNG
The total IPNG score was 183.85 for the entire population, which is within the shared
governance range (173–344). Likewise, all subscale scores were consistent with levels of
shared governance, namely that nurses reported that decision making is shared between
themselves and administration in all subscales except personnel.
For the subscales, the nursing personnel mean score was 37.89, which is below the range
expected for shared governance (44–88), reflecting little shift toward including staff nurses in
the decision-making process. For the other subscales, participants’ scores reflect that the
shared governance model had been implemented recently. In relation to information (who
has access to governance activities information), respondents reported a mean score of 34.9,
falling within the shared governance range (31–60); the goals subscale (related to who sets
goals and negotiates resolution of conflict at different organisational levels) had a mean score
of 17.58, on the borderline of the shared governance range (17–32). Resources (who supports
professional practice that impacts resources) showed a mean score of 31.18, within the
shared governance range (27–52). Participation (who develops and participates in
structures like the governance committee) had a mean score of 25.27, on the borderline of
the shared governance range (25–48). Lastly, practice (who controls professional practice)
had a mean score of 37.02, which falls within the shared governance range (33–64) (see
Table 2).
One-way ANOVA was used to identify whether there was a significant difference
associated with reporting of shared governance levels and specific occupation. The results
Khraisat et al. 7

Table 2. Descriptive statistics for the six Index of Professional Nursing Governance (IPNG) summative
subscales (n ¼ 307).

Subscale Shared governance range Mean SD Minimum Maximum

Total IPNG Score 173–344 183.85 40.95852 100 322

1. Personnel 44–88 37.8925 13.15338 22 83
2. Information 31–60 34.8990 9.26125 15 60
3. Goals 17–32 17.5798 5.59785 8 34
4. Resources 27–52 31.1824 8.48408 13 58
5. Participation 25–48 25.2736 7.28348 12 51
6. Practice 33–64 37.0195 9.08779 16 97

Table 3. Index of Professional Nursing Governance (IPNG) total score by Unit, One-way ANOVA
(n ¼ 307).

Unit Mean SD F Significance

Medical 184.23 35.603

Surgical 188.17 46.256 2.191 0.018
Critical care 183.70 40.613
Operating theatre 209.21 52.688

showed a significant difference between nurses regarding the shared governance level
according to working units (i.e. medical, surgical, critical care, operating theatre)
(F ¼ 2.191, p ¼ 0.018) (see Table 3).
The Scheffe post hoc test indicated a statistically significant difference between surgical
and medical units toward the surgical unit (p ¼ 0.047), and between the operating theatre
and critical care toward the operating theatre (p ¼ 0.034) (see Table 4).

Discussion
The results of this study indicate the IPNG measure (Hess, 1998) is a suitable tool for
measuring shared governance decision making. The current study is the first in Saudi
Arabia to assess the shared governance level at a children’s hospital. Shared governance
was reported by nurses at different management levels within the satisfactory IPNG range of
173–344, excluding the personnel subscale, where nurses reported limited control over their
professional decision-making practice.
Hospitals are constantly looking for opportunities to improve their performance by
providing quality-based, and cost-containment care (Powers and Bacon, 2106; Wilson
et al., 2014). To enhance nursing care and progress the health setting’s overall
performance, shared governance has been combined with nursing infrastructures to
provide a framework. Shared governance infrastructure has the ability to provide nurses
with the opportunity to be partners in nursing management, to reach optimal patient and job
satisfaction, productivity, and reduced turnover of staff (Al-Faouri et al., 2014; Powers and
Bacon, 2106).
8 Journal of Research in Nursing 0(0)

Table 4. Post hoc test results (n ¼ 307).

(I) Unit (J) Unit Mean difference (I – J) Standard error Significance

Medical Surgical 19.10575 9.56890 0.047

Critical care 49.32308 19.62278 0.12
Operating room 20.52593 9.78204 0.37
Surgical Medical 19.10575 9.56890 0.047
Critical care 48.33333 18.94285 0. 11
Operating room 21.71474 9.78498 0.27
Critical care Medical 49.32308 19.62278 0.12
Surgical 48.33333 18.94285 0. 11
Operating room 25.51786 12.00722 0.034
Operating theatre Medical 20.52593 9.78204 0.37
Surgical 21.71474 9.78498 0.27
Critical care 25.51786 12.00722 0.034

Shared governance range

Many studies have reported lower, borderline results in the shared governance range (Al-
Faouri et al., 2014; Anderson, 2011; Barden et al., 2011; Lamoureux et al., 2014). The
rationale might be related to poor participation in multi-functional shared services, and
the absence the transformational leadership to mediate the relationship between
structurally empowering working conditions and patient-care quality (Bamford-Wade and
Moss, 2010). It could be associated with hospital nurses carrying out isolated, routine tasks,
rather than using their professional training because they are subject to control by
organisational and medical divisions of labour. The environment may disturb a nurse’s
ability to practice according to professional standards.

Personnel subscale
The results revealed that, in the nursing personnel subscale, nurses reported limited control
over their professional practice in their formal organisation; this subscale had the lowest
mean score of all the subscales, indicating that decisions are not shared equally by staff
nurses and nursing management. Hess (1998) reported that only 1 of 16 hospitals had
acceptable shared governance in nursing personnel scores. Similarly, Barden et al. (2011)
and Overcash et al. (2012) found that nursing reports of their working environment were
more closely related to a traditional governance structure. However, in Jordan, nurses
reported that the practice of shared governance is more professional when the
environment provides opportunities and structural empowerment through resources,
support and information (Afeef et al., 2010).

Information subscale
In the current study, nurses identified additional access to information in areas such as
resources, fresh advances in nursing practice, compliance of the hospital in terms of
nursing practice with requirements for measurement of agencies, and strategic plans for
Khraisat et al. 9

the coming years. Participation in quality activities, an orientation program for new nurses,
an annual training plan for the nursing departments and access to library facilities within the
hospital might explain the results. These findings (mean ¼ 32) were consistent with other
studies (Afeef et al., 2010). and fall within the shared governance ranges of Wilson et al.
(2014).

Goals subscale
In relation to questions about who sets the goals and negotiates the resolution of conflict
at different organisational levels, the mean score of 17.58 fell within the lower limit of
the shared governance range (17–32). These results are consistent with the mean scores
of other studies e.g. Afeef et al. (2010) (mean 17), Lamoureux et al. (2014) (mean 16),
and Wilson et al. (2014) (mean 18). Mahmoud (2016) recommends that engaging
nurses in decision making, work redesign and conflict resolution could improve their
empowerment. Therefore, nurses need more knowledge and training regarding conflict
negotiation strategies to improve their ability to advocate for, and provide quality care
to, patients.

Resources subscale
The mean score of 31.18 remained higher than five facilities previously surveyed by Hess
(1998) and which were characterised as shared governance hospitals. The participants in the
present study have formal authority in a variety of procedures such as everyday patient care,
consulting services and creating schedules, the means confirming those from earlier studies.
Other studies revealed similar results e.g. Afeef et al, (2010) (mean 32), Lamoureux et al.
(2014) (mean 33.5) and Wilson et al. (2014) (mean 34.8).

Participation subscale
The mean score for participation in the current study was 25.27, just within the shared
governance range (25–48). The nurses stated a limited ability to participate in committees
that relate to strategic planning, multidisciplinary professionalism, organisational budgets
and expenses. However, they had shared ability with nursing management/administration to
participate on most committees, particularly those related to clinical practices within the
unit, and staff scheduling.

Practice subscale
Nurses reported adequate input in the parts of the healthcare system that directly touch on
patient care (mean 37.2); for example, standards of patient care, improvement of care
quality, progress in health education, products for the nursing care plan and integrating
research in nursing. Nevertheless, they reported incomplete control over the model of
nursing care for their professional work and staffing levels. The rationale for this
reporting could be related to the active role of accreditation drivers, which gives an
opportunity for nurses to contribute to categorising and reviewing the patient-care
standards needed, and to apply quality improvement projects and the implementation of
10 Journal of Research in Nursing 0(0)

evidence-based practice projects recently introduced into the hospital. The result is
consistent with Afeef et al. (2010), where the mean score was 37.

Conclusion
The findings of this study showed that the nurses’ decision making is shared by staff and
managers in the majority of IPNG subscales (information, goals, resources, participation
and practice). The nurses working in operating theatres and surgical units reported more
shared governance than nurses in critical care units and medical wards. There was no
difference between nurses at staff and manager level regarding shared governance level.
The study has implications for improving nurses’ working environments and enhancing
shared governance. These findings can be used as recommendations for shareholders and
nursing leaders to implement a suitable model of shared governance inside hospitals.
Furthermore, research using focus groups to discuss shared governance in nursing
practice might identify the challenges handled by many nurses, and lead to essential
interventions.

Limitations
Considering the importance of the issue studied, the limitations of this study must be
considered in interpreting the results. The study involved a small sample of nurses from
four units, and the findings may not be representative of the level of shared governance
among nurses in other settings. In addition, this study was limited to one hospital located in
Riyadh - the capital, which limits the external validity of the findings. Future research should
include additional studies with a larger sample size recruited from other hospital settings.
More descriptive and longitudinal studies are still needed to gain a comprehensive
understanding of the outcomes of shared governance in Saudi hospitals. This is an
important step before moving to interventional studies. Polit and Beck (2010) advised that
interventions often fail because they are designed without an adequate understanding of the
problem or the relationship between variables.

Recommendations
Meanwhile, according to the literature, there is insufficient study of Saudi children’s
hospitals discussing this issue; nursing educators need to focus more on the concept of
shared governance and decision-making involvement for their students. Availability of
training in shared governance skills for all nurses, and especially for nurse managers, is a
requirement. Administrators can use the findings of this study to progress or support models
for shared governance, training nurses and nurse managers about shared governance and
decisional involvement behaviours and how they affect nurses’ job satisfaction.
Implementation of certain skills by nurse managers might lead to a new environment of
organisational culture, encouraging a mood of creativity in conflict, direct management,
group-work, autonomy, a sense of motivation and empowerment. Thus, the integrated
shared governance model may serve as a valuable tool for organisations to achieve
optimal health outcomes for the patient, nurses and system. Qualitative methodology is
still needed to gain a comprehensive understanding of the shared governance model in
children’s’ hospitals.
Khraisat et al. 11

Key points for policy, practice and/or research

. Nurses in Saudi children’s and young people’s hospitals need more awareness with
regards to the shared governance concept.
. Stakeholders and nursing leaders may adopt a suitable model of shared governance in
children’s hospitals using the findings of this study.
. The principles of shared governance provide a model of structural empowerment
commonly used to integrate the Magnet accreditation standards to achieve desirable
patient, nurse and system outcomes.

Acknowledgements
The authors would like to thank all who assisted in this study.

Declaration of conflicting interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or
publication of this article.

Ethical permissions
Ethical permission was obtained through the Research Ethics Board. Participants were recruited with
an invitation letter and information sheet about the study. Participants were assured that their
participation was voluntary and that they could withdraw from the study at any point without penalty.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or
publication of this article: This work was supported by Al-Ahliyya Amman University (AAU).

ORCID iD
Omar Khraisat https://orcid.org/0000-0002-8024-9708

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Omar Khraisat is an Assistant Professor, Former Assistant Dean for Training Affairs. PhD
from the University of Jordan. Research focus is on pediatric palliative care, quality of care,
patient safety, and community health nursing.

Khetam Al-awamreh is an Associate Professor, former Chairperson of the Maternal and

Child Health Department at the Faculty of Nursing. Research focus is on the maternal
and child health nursing.

Mahmoud Hamdan is a Director of the Magnet Program. His research focus is on the quality
of care, and patient safety.

Mohammed AL-Bashtawy is a Full Professor, Former Dean of Nursing College. Research

focus is on community health nursing.

Abdullah Al khawaldeh is an Associate Professor, Former Dean of Nursing College.

Research focus is on community health nursing.

Mohammad Alqudah is a Clinical Instructor. Research focus is on youth mental and

psychological health.

Jamal A. S. Qaddumi is an Assistant Professor. Research focus is on the quality of care.

Samer Haliq is a Lecturer. Research focus is on quality of care, patient safety, and
emergency services.