J Nurs Care Qual

Vol. 00, No. 00, pp. 1–7

Copyright c 2017 Wolters Kluwer Health, Inc. All rights reserved.

Decisional Involvement
Differences Related to Nurse
Characteristics, Role, and Shared
Leadership Participation
Shelly A. Fischer, PhD, RN, NEA-BC, FACHE;
Dawn Horak, MSN, RN, CPPS, CEN;
Lesly A. Kelly, PhD, RN

A sample of 1933 registered nurses working in 24 hospitals with shared leadership was surveyed to
examine perceptions of nurse decisional involvement. Council participation was associated with
higher decisional involvement scores (P = .03), and nurse experience was a statistically significant
predictor of decisional involvement (P < .01). Nurse manager and staff registered nurse scores
were significantly different (P < .01). Shared leadership may promote staff nurse perceptions
of involvement in decision-making. Key words: decision making, leadership, nurse manager,
shared leadership, staff nurses

A S HEALTH care organizations face the

growing challenge of improving quality
of care while reducing costs, hospital manage-
shown to improve organizational culture and
outcomes.1 Involvement in decision-making
is an important aspect of shared leadership
ment teams are reevaluating nursing staff en- in nursing. Shared leadership has been de-
gagement and performance strategy. A com- fined as an organizational culture that em-
mon approach for improving quality and staff powers frontline employees to engage in
satisfaction is to implement a shared lead- decision-making with the formal leaders of the
ership professional practice model, as front- organization.2
line engagement in decision-making has been Participative management is another term
commonly associated with shared leadership,
defined as a leadership environment that en-
Author Affiliations: Fay W. Whitney School of courages staff at all levels of the organization
Nursing, University of Wyoming, Laramie to contribute to decision-making.3 However,
(Dr Fischer); Banner Health, Phoenix, Arizona shared leadership is more than a participative
(Dr Fischer and Ms Horak); and Arizona State
University, Banner—University Medical Center management approach; it is a professional
Phoenix (Dr Kelly). practice model based on shared account-
The authors declare no conflicts of interest. ability, authority, and decision-making.4
Implementation of council structures and
Supplemental digital content is available for this article.
Direct URL citation appears in the printed text and is decision-making processes within the nursing
provided in the HTML and PDF versions of this article department fosters and encourages staff nurse
on the journal’s Web site (www.jncqjournal.com). involvement in decision-making, thereby cul-
Correspondence: Shelly A. Fischer, PhD, RN, NEA-BC, tivating a culture of shared leadership among
FACHE, Fay W. Whitney School of Nursing, University all levels of nursing employees within the
of Wyoming, Banner Health, 1000 E. University Ave
Dept 3065, Laramie, WY 82071 (Sfische1@uwyo.edu). organization. International appeal of shared
leadership as a nursing professional practice
Accepted for publication: October 27, 2017
model has grown,5-7 especially in response
Published ahead of print: December 18, 2017
to growing popularity of Magnet recognition
DOI: 10.1097/NCQ.0000000000000312 in countries outside of the United States.8-10
1

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 2 JOURNAL OF NURSING CARE QUALITY /00 2017

BACKGROUND tion. A structure like the councilor model en-

ables organizations to evaluate processes and
Shared leadership model definition improve performance across an entire organi-
and benefits zation rather than just at the unit level.
Shared leadership is characterized by “con- Once a shared leadership professional prac-
texts in which leadership and influence are tice model is implemented, it is important
distributed across the teams.”2 Work environ- to measure its effectiveness. One measure of
ments that reflect participative management effectiveness is the degree to which it has
and decentralized decision-making, 2 integral increased engagement of staff nurses. The
components of shared leadership, have expe- degree to which a health care organization
rienced improved staff satisfaction and reten- has integrated its staff nurses into decision-
tion, as well as lower levels of burnout and job making processes may reflect how well that
stress.12-14 In health care settings, staff nurses organization has implemented the profes-
must feel empowered, involved in decision- sional practice model of shared leadership11
making, and given access to support in or- and how well the model is working to engage
der to foster a climate of patient safety and staff nurses in decision-making about things
to optimize clinical outcomes.15-18 Empower- that affect their practice. Thus, decisional
ment, participatory change management, and involvement can be a reasonable measure
shared leadership are key characteristics of of shared leadership effectiveness. Overall,
Magnet hospitals. Research has shown that understanding how to engage and involve
staff nurses working in Magnet hospitals per- nurses is essential to effective leadership and
ceive greater empowerment and job satisfac- achievement of strategic objectives.
tion than staff nurses working in non-Magnet The empowerment of nurses through a
facilities.16,19 Staff nurse decisional involve- professional practice model of shared lead-
ment has also been associated with lower than ership is associated with improved patient
average patient mortality20,21 and with fewer care outcomes, improved recruitment and re-
patient complaints.22 tention of nurses, and decreased cost25 ; yet
Implementation of a shared leadership pro- few research studies examine the effective-
fessional practice model creates an organiza- ness of the model once implemented. Given
tional culture that encourages nurses at all the need to evaluate the current shared lead-
levels to participate in decision-making by ership model, particularly its effects on staff
providing structure and processes that en- nurse decisional involvement, this descriptive
able empowerment at a grassroots level.23 The study was undertaken to examine the differ-
councilor model is commonly used and is re- ences in perceptions regarding nurses’ actual
garded by many as the most adaptable and and preferred levels of decisional involvement
sustainable approach to shared leadership.24 at the unit level.
The councilor model commonly employs sep-
Leadership influence
arate councils, or groups of nurses, to address
different types of decision-making. For exam- Nurse administrators and managers have
ple, unit-based councils contribute represen- a significant impact on the implementation,
tatives to house-wide councils: perhaps, one and the ultimate success, of professional prac-
to address nursing care quality and safety, tice models. Leaders who are ill-prepared for
and another council for nursing education, the power shift required by a shared leader-
research, and evidence-based practice. Fre- ship model may block the implementation
quently, a coordinating council exists within of this model.11 When managers can com-
the councilor model of shared leadership to pare management’s and staff’s perceptions of
coordinate the activities of the councils, in staff nurse involvement in decision-making,
addition to providing a mechanism for hori- they have a feedback mechanism and a means
zontal and vertical bidirectional communica- of fostering open discussion with staff. Yet,

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 Decisional Involvement 3

studies evaluating perceptual differences be- the US. All hospitals had implemented a coun-
tween management and staff nurses are cilor model of shared leadership, with matu-
lacking.26 rity of the shared leadership culture varying
from facility to facility. The inclusion crite-
Nurse characteristics
ria included all full- and part-time staff nurses
Because perceptions are largely developed and nurse managers employed at the partici-
through individuals’ history and previous pating hospitals in roles that required an RN
experience, in designing this study it was license. Temporary personnel were excluded
important to know which nurse charac- from the study, as they rarely if ever partici-
teristics (years of experience, certification, pate in shared leadership councils due to the
educational preparation, and experience transient nature of their employment with the
with shared leadership) might be associated nursing units. Before data collection, the au-
with perceptions of involvement in decision- thors gained approval of the project by institu-
making. In one previous study, education tional review board of the health care system.
level was the only nurse characteristic
associated with scores of actual decisional Instrument
involvement,6 while in other studies, edu- The instrument selected and used with
cation level was not significantly associated permission for this study was the Decisional
with actual or preferred levels of decisional Involvement Scale (DIS).22 Nursing decisional
involvement.5,27 involvement is defined as the distribution
of power for decision-making related to
Purpose
issues and tasks that affect nursing practice.28
The purpose of this study was to examine The DIS uses a 1 to 5 scale (1 = Decisions
the influence that nurse characteristics, role, usually made exclusively by nursing man-
and shared leadership participation have agement/administration and 5 = Decisions
on nurses’ perceptions of involvement in usually made exclusively by staff nurses) to
decisions that affect their practice. Research indicate the degree to which staff nurses are
questions included the following: What are involved in decision-making. The DIS has
the relationships among nurse characteristics been used to measure perceived levels of de-
(education, experience, certification), nurse cisional involvement by hospital staff nurses
role (staff or management), and participation and members of nursing leadership. The scale
in a shared leadership councilor model (yes also assesses and measures the gap between
or no), with nurses’ perceptions of actual and actual and desired levels of decisional involve-
preferred decisional involvement? ment, as well as the level of agreement be-
tween staff and management perceptions.28
METHODS While other instruments exist to specifically
measure shared governance,11 the DIS was se-
Design lected to measure decisional involvement as it
A nonexperimental descriptive survey de- relates to shared leadership, as an indicator of
sign was used for this study. The survey the effectiveness of the context and content
was distributed to acute care nurses through associated with a shared leadership model.
e-mail using a Web-based tool to collect de- The development of the DIS was guided
mographic information and measure nurses’ and informed by a professional practice
perceptions of decision-making. model of nursing that emphasizes collab-
orative practice and management with
Setting and sample professionals in contrast to the management
A convenience sample consisting of regis- of professionals.22 Previous studies find the
tered nurses (RNs) in staff and management reliability of the DIS to be reasonable for a
roles in 1 health system across 7 states within new scale for all subscales (Cronbach α =

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 4 JOURNAL OF NURSING CARE QUALITY /00 2017

0.68-0.85) and high for the scale as a whole experience, certification, and participation in
(Cronbach α = 0.91-0.95).27,28 Another shared leadership) and their perceptions of
important justification for choosing this in- actual and preferred decisional involvement,
strument was its brevity; survey fatigue can be correlations among the variables were con-
a significant detractor to high response rates. ducted. Finally, to assess differences between
The DIS consists of 21 items that measure staff nurse and nurse manager perceptions re-
actual and desired decisional involvement, for garding actual and preferred levels of nursing
a total of 42 scored items per survey. The time staff decisional involvement, t tests were con-
demand for completion of the DIS question- ducted between staff RN and nurse manager
naire is less than other instruments and was DIS scores.
thought to be within reason for most nurses to
complete while on duty. The DIS instrument RESULTS
is available in a previous publication.22
Six subscales of the DIS may be analyzed Overall, 1933 completed questionnaires
independently or may be added together for were returned, yielding an estimated 20% re-
a total score (range of possible total 21-105). sponse rate, approximated from an e-mail list-
The subscales are as follows: (1) unit staffing, serv total of 9900 nurses. As a result of re-
(2) quality of professional practice, (3) profes- dundancy in demographic responses, 2 cases
sional recruitment, (4) unit governance and were deleted, resulting in a final sample of
leadership, (5) quality or support staff prac- 1,931 responses. Supplemental Digital Con-
tice, and (6) collaboration/liaison activities. A tent Table, available at: http://links.lww.com/
high total score indicates a high degree of staff JNCQ/A405, shows characteristics of the sam-
nurse involvement in decision-making, and a ple, including demographics and nurse char-
low score suggests a low degree of staff nurse acteristics.
involvement.
Influence of individual characteristics
Data collection Actual DIS scores were significantly corre-
The investigators e-mailed all nurses who lated with years of experience (r = 0.07, P <
met inclusion criteria with an invitation to par- .01) and shared leadership participation (r =
ticipate in this study. The survey consisted of 0.05, P < .05). Actual DIS scores were not sig-
12 demographic questions and the 21-item, nificantly correlated with nursing education
2-column DIS. Reminder e-mails were sent or certification. Preferred DIS scores were cor-
at 1-week intervals for 3 consecutive weeks related with number of years of experience
to encourage participation. Informed consent (r = 0.09, P < .01) but not with shared leader-
was implied by completion and submission of ship participation, nursing education, or cer-
the anonymous survey. tification. The Table presents the correlations
among individual RN characteristics and ac-
Data analysis tual and preferred DIS scores.
Analysis was conducted using SPSS version
22 (IBM, Armonk, New York). Descriptive Influence of role
statistics were conducted to describe the sam- Managers had a higher overall actual deci-
ple characteristics. A multiple analysis of vari- sional involvement score (M = 46.33, SD =
ance was conducted to test for mean differ- 14.82) than did staff nurses (M = 41.95, SD =
ences with the actual and preferred total DIS 15.88), t1,931 = 5.36; P < .01. Staff nurses had
score as the dependent variables and with slightly higher preferred scores (M = 58.48,
shared leadership participation (yes or no) SD = 12.16) than did managers (M = 57.27,
as the independent variable. To examine the SD = 11.45), although this difference was
relationships among nurses’ individual char- only marginally statistically significant, t1,931
acteristics (educational preparation, years of = 1.89; P = .06. The comparison that is likely

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 Decisional Involvement 5

Table. Correlations Among Nurse Characteristics and Total Scores

1 2 3 4 5 6 7

1. Nursing education ...

2. Years of experience 0.110a ...
3. Shared leadership 0.150a 0.100a ...
4. Management role 0.270a 0.220a 0.270a ...
5. Current certification − 0.009 − 0.002 0.010 0.067a ...
6. Actual DIS total score 0.010 0.070a 0.050b 0.120a 0.032 ...
7. Preferred DIS total score 0.040 0.090a 0.010 − 0.04 0.010 0.420a ...

Abbreviation: DIS, Decisional Involvement Scale.

a P < .01.
b P < .05.

most important in the analysis of staff RN 0.18; P = .67. Shared leadership participation
versus management perceptions is the disso- was associated with a perception of greater
nance between actual and preferred scores involvement in decision-making and yet was
for each group: the mean difference in actual not associated with greater preference for
and preferred scores between the groups was involvement.
−0.267 (95% confidence interval: −0.332 to
0.201), which is a significant difference (P < DISCUSSION
.001). This result indicates incongruence in
views, suggesting that there is a potential for
The purpose of this study was to assess
dissatisfaction among staff RNs that is not un-
the influence that nurse characteristics, role,
derstood by nurse managers, largely due to
and shared leadership participation have on
differences in perception of the gap between
perceptions of decisional involvement. Anal-
what is actual and what is preferable.
ysis of actual and preferred decision-making
demonstrated that, in general, nurses de-
Influence of shared leadership
sired greater involvement in decisions affect-
participation
ing their practice than they had. Analysis
The specific aims of the study included de- of nurse characteristics indicated that nurses
scribing the effect of shared leadership coun- with more experience and involvement in
cil participation on actual and preferred levels shared leadership models felt more involved
of staff RN decisional involvement. The actual in decision-making than did less experienced
and preferred total DIS scores were depen- nurses and those who had not participated in
dent variables, and shared leadership partici- councils. Nurse managers believed that staff
pation (yes or no) was the independent vari- RNs had greater involvement than the staff
able. While the multivariate model was only RNs themselves felt they had, and the gap
marginally significant (P = .07), actual total between actual and preferred involvement
DIS scores were higher for those with shared was greater for nurses than was perceived by
leadership participation (M = 43.61, SE = nurse managers.
0.45) than those without shared leadership The study’s most predictable result was
participation (M = 41.99, SE = 0.58), F1,1931 = that nursing experience and participation in
4.86; P = .03. Preferred total DIS scores did shared leadership councils were associated
not differ between those with shared lead- with greater perceptions of actual levels of in-
ership participation (M = 58.29, SE = 0.35) volvement in decision-making. This might be
and those without shared leadership partic- explained by the tendency for the expert bed-
ipation (M = 58.05, SE = 0.44), F1,1931 = side nurse to be, overall, more confident and

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 6 JOURNAL OF NURSING CARE QUALITY /00 2017

vocal with ideas and opinions as compared mation that inform nursing and guide profes-
with new or novice nurses. Other findings sional practice improvement efforts. The mea-
from the study were less expected. One result sure should not be construed as an absolute
that could raise concern is the difference in measure of effectiveness, other than in evalu-
perceptions between managers and staff, es- ations of strategic efforts aimed at increasing
pecially in terms of actual involvement scores. decisional involvement.
This indicated a gap in the views of reality be-
tween the 2 groups; the gap may be explained CONCLUSION
by a mere lack of communication, but perhaps
a deeper disconnect is indicated. Regardless, This study highlights areas for additional
attention from nursing leadership. First, a
further attention to this finding is warranted.
An important finding of the study is related to check-in between staff and leadership is essen-
the value of shared leadership as a strategy for tial to validate differences and similarities in
perception of the culture. Awareness of how
engagement and improving nurses’ percep-
tion of involvement in decision-making. Be- staff perceives the work culture is an impor-
cause the shared leadership model is intended tant first step in identifying strategic opportu-
nities for organizational and leadership devel-
to engage frontline staff in decision-making, it
is valuable to know that there is a relationship opment. Finally, identifying specific areas for
focus and improvement in shared leadership
between a perception of greater decisional in-
culture offers the greatest return on invest-
volvement and participation in councils. This
finding also supports the use of the DIS as a ment of time and energy. Each nursing unit
should be assessed to identify areas of great-
measure for the effectiveness of shared lead-
est decisional involvement dissonance, which
ership as a decisional engagement strategy.
While these findings may be unique to inpa- can be targeted for improvement efforts; in ad-
dition, areas of least dissonance can be iden-
tient settings, they are not limited to nursing
in the United States. Desire for decisional in- tified for purposes of celebration and sharing
volvement reaches well beyond geographic, of best practices.
As more health care organizations focus
ethnic, and cultural boundaries.6
on delivering high-quality care and ensuring
patient safety with limited resources, shared
Limitations leadership can support achievement of orga-
Efforts were made to limit social desirabil- nizational goals. The employment of a shared
ity bias by reassuring participants that find- leadership model that works in real time can
ings would be reported to administration in be beneficial not only for helping the organi-
aggregate only; still, the potential remained zation to meet performance targets but also
that nursing staff would respond in ways that for promoting staff satisfaction and retention.
they believed their supervisors would prefer. Measuring actual and perceived levels of de-
Another limitation of the findings is that the cisional involvement can provide a starting
perceived levels of decisional involvement are point to better understand the nursing work
mistaken as being equal to the actual levels of environment. The DIS may be used as a di-
decisional involvement or to the actual lev- agnostic or evaluative measure within these
els of shared leadership. This measure, per- settings, as well as in settings where the imple-
ceived level of decisional involvement, should mentation of a shared decision-making model
constitute just 1 among several types of infor- is anticipated.

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