Introduction

Governance is a topic that should be explored in the management research field in general and nursing and health management specifically. It can help increase nurses’ autonomy and scope of responsibilities. In the health care area, the use of the term governance has been growing, especially in the context of discussions about good management practices that could be adopted to improve care delivery for individuals and population. A principle of governance is the participation and involvement of professionals in management and decision making process at organizations and health services, these professionals should be as committed as his/her managers with results of care to be achieved (Santos et al., 2013).

The changing context of society and healthcare called for a restructuring of hospital administration that emphasized collaboration, a defined knowledge base, autonomous practice, and shared decision making. Moreover, nurses are the closest to patients and the point of care. They hold scientific knowledge upon which to provide care across the continuum of healthcare services. Furthermore, nurses have the unique ability to partner with other health care professional in redesigning the healthcare system (Charland, 2015).

In the context of nursing, professional governance corresponds to the processes and structures that provide autonomy, control and authority to nurses regarding the nursing practices within an organization (Barden et al., 2012). The first governance model for nursing was designed in the 1980s, in the United States, and called “shared governance” (Hess & Swihart, 2013; Santos et al., 2013). The model is based on the assumption that nurses, as the main frontline health workers, are more qualified to assess and decide which are the care needs of patients, based on parameters of clinical practice guidelines (Barden et al., 2012; Hess & Swihart, 2013).

Shared governance is seen as a strategy to build a partnership, create ownership, and facilitate equity and accountability between the nurses and the work environment (Al-Faouri et al., 2014). As a management innovation, shared governance implementation was a strategy to enhance professional nursing practice to transform the organization from a bureaucratic, hierarchy to a more organic, relational partnership (Charland, 2015).

Autonomy has been described as having the authority to make independent decisions and to take actions in accordance with one’s discretion and professional knowledge. To function autonomously, however, nurses must develop the expertise that allows them to exercise sound clinical judgment and exert control over their practice. Certain satisfiers must be met, for example, resources must be provided and autonomy supported to achieve an adequate level of competency (Shepherd et al., 2014).

Significance of the Study

During supervising the rotations of clinical training for nursing students at Minia University Hospitals, the researcher noted different situations showing the number of assessments, decision-making, independent procedures, and interactions that a professional nurse might undertake within a single work shift, however, the authority given to nurses for independent judgment seems much more limited either by organizational constraints, legal/professional practice parameters, absence of specified job descriptions of nursing categories, or by the individual nurse’s own confidence and perception of competence.

In addition, it was noted also by the researcher that shared governance studies started to appear in the Egyptian nursing research.  Despite,  most of these studies were descriptive in nature mainly focusing on assessing the perceptions of shared governance and its relation to nurses empowerment, job satisfaction or organizational commitment, however, the present study was the first one to be carried out that involve monitoring the professional nurses' knowledge and perceptions of shared governance before and after implementing an educational program and to spotlights whether this educational intervention would affect their level of perceived autonomy.

Aim of the study:                                                                                                                 

The aim of this study was to investigate the effect of shared governance educational program on knowledge, perceptions and autonomy of professional nurses.

Research Hypothesis:

1)       Professional nurses' knowledge and perceptions of shared governance will be higher after the educational program than before.

2)       Professional nurses' level of autonomy will be different before and after the educational program.

3)       There will be a relationship between professional nurses' knowledge and perceptions of shared governance and their level of autonomy before and after the educational program.

Subjects and methods

Research design:

Quasi-experimental design was utilized in this study.

Setting:

The study was conducted in five of Minia University Hospitals including: (The Main University Hospital, Cardio-thoracic Hospital, Gynecology, Obstetrics and Pediatrics Hospital, Renal and Urology Hospital in addition to the Dental Hospital).

Subjects

The study sample included (78) nurse drained by the probability sampling technique from the total no (100) of baccalaureate prepared nurses working at the previously mentioned hospitals during the time of conducting the study.

Tools of data collection:

Two tools were used to collect the research data for this study as follows: -

Tool 1: Nurses Knowledge and Perceptions of Shared Governance Questionnaire.  It was consisted of three parts:

Part I: included the socio-demographiccharacteristics of the study sample as (age, gender, place of residence, current job position, years of experience and work department).

Part II: included 20 items developed by the researcher based on the literature reviewto identify nurses' knowledge of shared governance with 2 responses (1) I don’t know and (2) Yes I know. Total score of knowledge (˃ 60%) considered "satisfactory" level and otherwise considered "unsatisfactory" level.  

Part III: included 18-items adapted by the researcherfrom (Rundquist, 2014) to measure nurses' perceptions of shared governance on 3-point Likert scale ranged from (1) disagree, (2) neutral and (3) agree. The score was reversed for negative items. Total scores of (18-30) indicate "low", while scores (31- 42) considered "moderate" and scores (43-54) considered "high" level of perceptions. The higher score indicated that shared governance is perceived as favorable administrative system by the group of participated nurses.

Tool 2: Professional Nursing Autonomy Scale:

This tool was adapted by the researcher from the instrument originally developed by(Blegen, 1993) and used by (Mrayyan, 2005) to measure nurses' autonomy over patient care and unit operations decisions on a 5-point Likert scale ranging from (1) "Nurses have no authority nor accountability" to (5) "Nurses have full independent authority and accountability".  Total score of the scale ranged from (41 - 205) with scores of (41 - 95) indicated that participated nurses perceived their professional autonomy as "low" and from (96 - 150) indicated "moderate", while from (151 - 205) indicated "high" level of autonomy.

Validity of Tools

 Tools of the study were translated into Arabic by the researcher. Its content validity were revised and validated by a panel of five experts in nursing administration field including Two Assistant Professors in Nursing Administration Department – Faculty of Nursing – Minia University and Two Assistant Professors in Nursing Administration Department – Faculty of Nursing – Ain-Shams University in addition to One Assistant Professor in Nursing Administration Department – Faculty of Nursing – Beni-Suief University.  Accordingly, wording of some items were modified.

Reliability of Tools    

The reliability analysis of the study tools was done using alpha coefficient to measure the stability of its internal consistency; it was (0.72) for nurses knowledge and perceptions of shared governance questionnaire, while the test value for the autonomy scale was (0.89).

Pilot Study

A pilot study was done on 10% of participants (8 nurses) who were included in the study sample. They were selected randomly from the five hospitals where the study was carried out in order to check the applicability of tools, identify obstacles and problems that may be encountered during data collection and the estimate time needed to fill the questionnaires. In the light of the pilot study’ findings, no major changes occurred in the tools’ content or no. of items. So, tools were put in its final form.

Procedure

The study was conducted in three phases: Assessment and planning phase, implementation phase, as well as evaluation phase.

i- Assessment and Planning Phase:

Thisphase took up approximately nine months through which the researcher obtained the official permission from the Dean of Nursing Faculty, Minia University and from Managers of the five university hospitals where the study was carried out and approached the Jury committee for testing the content validity followed by conducting the pilot study and reliability analysis of the study tools.  During this phase a review of the related literature covering various aspects of the study variables was done for collecting and organizing the theoretical framework of the study as well as preparing  the Arabic booklet containing the scientific content of the program that was distributed to participants at the end of program implementation.

ii- Program Implementation Phase:

This phase involved  obtaining an official permission from the Dean of  Faculty of Medicine as the Chief Officer of Minia University Hospitals for organizing the conduction of the educational sessions of the program at Minia University Hospitals in coordination with the Chief Nursing Managers responsible for The Center of In-service Training and Continuing Education. Application of the program had taken six months at the five hospitals consequently. 

iii- Evaluation and follow -up Phase:

This phase included monitoring the participated nurses' knowledge and perceptions of shared governance in addition to their level of autonomy by using the study tools. It was started jointly with the implementation phase and continued for six months later from the end of implementing the program at the last hospital setting.

Ethical considerations                                                                                                             

• Written Approval was taken from Ethical Committee in the Faculty of Nursing – Minia University.
• Participation in the study was on voluntary basis and stating the possibility to withdraw at any time.
• Explaining the purpose and nature of the study was done before submitting tools of the study to the participants at each attempt of data collection for pre, post and follow-up tests and at the beginning of each educational session during the implementation phase of the program.  ,
• Privacy and confidentiality of the participants' information was assured. Participants were reassured that their anonymity was maintained and the collected information wouldn't be used except for the purpose of this scientific research.

Statistical design

Data were analyzed using the statistical package for social science (SPSS) version 22. Numerical data were expressed as mean and SD. Quantitative data were expressed as percentage and percentage. For quantitative data, comparison between two variables was done using t-test, and comparison between more than two variables used ANOVA test. Chie–Square test was used for comparisons among the study variables at different periods of measurements.  Relations between different numerical variables were tested using Spearman's correlation. Probability "p-value" (˂ 0.05) was considered significant and (˂ 0.01) was considered highly significant.

Results   

Table (1): Percentage distribution of  the participated nurses according to their socio-demographic characteristics (n=78):

Table (1) shows that (57.7%) of the participated nurses were in the age group "31-40 yrs. ". The majority of them (71.8%) were females. More than half of participants (56.4%) were resided in rural areas and (82.1%) working as nurse managers. The large proportion (55.1%) had "11-20" years of experience. About one third (30.8%) were working in "Outpatients, ER, DR & OR" departments.

Figure (1): Percentage distribution of nurses' knowledge of shared governance level at different periods of measurements (n=78)

Pre –test = before implementing the educational program.       Post –test = immediately after  program implementation.

Follow-up 1 = after 3 months and. Follow-up 2 = after 6 months from implementing the educational program.

Figure (1)reveals that, near to one third of the participated nurses (29.5%) had "unsatisfactory "knowledge of shared governance level and (70.5%) of them had a "satisfactory "level of knowledge in the pre-test. While, immediately after implementing the program "post-test" and in the 1^st follow-up test there was only (7.7%) of the participated nurses had "unsatisfactory "level of knowledge and the percentage of nurses who had a "satisfactory " level of knowledge became (92.3%). In the 2^nd follow-up there was little change in the knowledge level among participated nurses , as there was (91%) of them had a "satisfactory"  level of knowledge and (9.0%) had a "unsatisfactory " knowledge level.

Figure (2): Percentage distribution of nurses' perceptions of shared governance level at different periods of measurements (n=78)

Pre –test = before implementing the educational program.       Post –test = immediately after program implementation.

Follow-up 1 = after 3 months and. Follow-up 2 = after 6 months from implementing the educational program.

Figure (2) shows that, in the pre-test there was (5.1%) of the participated nurses had "low "level of perceptions and the percentages of nurses who had a "moderate "and " high" levels  were (43.6%) and (51.3%) respectively. While, immediately after program implementation "post-test" the percentages of nurses who had "low", "moderate "and " high" levels were (1.3%), (24. 3%) and (74.3%) respectively. In the 1st follow-up test there was (7.7%) of the participated nurses had "low"  level of perceptions  and the percentage of nurses who had "moderate "level became (17.9%) while the percentage of nurses who had "high "level wasn’t changed from that in the post-test. In the 2nd follow-up there was little change among the participated nurses as the percentages "low", "moderate "and " high" levels of perceptions were (7.7%), (20. 5%) and (71.8%) respectively.

Figure (3): Percentage distribution of nurses' level of total autonomy at different periods of measurements (n=78)

Pre –test = before implementing the educational program.       Post –test = immediately after  implementing the educational program.

Follow-up 1 = after 3 months and. Follow-up 2 = after 6 months from implementing the educational program.

As evidenced by figure (3) that, the majority of the participated nurses perceived their total autonomy level as "moderate " with the following percentages (59.0 %; 61.5%; 74.4% & 65.4 %)  in the pre, post, 1^st and 2^nd follow-up tests respectively. In the other hand, the percentages of "low" level were (32.0%; 25.6%; 16.6%, & 15.4%) respectively. While, the percentages of "high "level were (9.0 %) in both the pre and 1^st follow-up tests and were (12.8 %, & 19.2%) in the  post and 2^nd follow-up tests respectively.

Table (2): Comparison of total mean score in nurses' knowledge and perceptions of shared governance level at different periods of measurements (n=78): 

Pre –test = before implementing the educational program.       Post –test = immediately after  program implementation.

Follow-up 1 = after 3 months and Follow-up 2 = after 6 months from implementing the educational program.

P₁= pre and post program implementation                P₂ = pre and after three months of program implementation

P₃= pre and after sixth months of program implementation.

It is observed from table (2) that, there was a high statistically significant difference in the total level of knowledge of shared governance among participants of the study at different periods of measurements (p-value (X2 df)= 0.000 (1) with), Mean & Std. Deviation scores of total knowledge level were (1.71 + .459; 1.92 + .268; 1.92 + .268 & 1.91 + .288)) in the pre, post, 1st &2nd follow-up tests respectively.

This table also indicates that, there was a high statistically significant difference in the perceptions of shared governance level among participants of the study at different periods of measurements (p-value (X2 df)= 0.000 (2) with Mean & Std. Deviation scores of total level of perceptions were (2.46 + .596; 2.73 + .475; 2.67 + .617; 2.64 + .624)) in the pre, post, 1st  and 2nd follow-up tests respectively.

Table (3): Comparison of total mean score in nurses' level of autonomy at different periods of measurements (n=78): 

Pre –test = before implementing the educational program.       Post –test = immediately after  implementing the educational program.

Follow-up 1 = after 3 months and Follow-up 2 = after 6 months from implementing the educational program.

P₁= pre and post program implementation                P₂ = pre and after three months of program implementation

P₃= pre and after sixth months of program implementation

As evident in table (3), there was a high statistically significant difference in the level of total autonomy as well as in the level of both autonomy over patient care decisions and over unit operations among participants of the study at different periods of measurements (p-value (X² df)= 0.000 (2) with Mean and Std. Deviation scores in the pre, post, 1^st and 2^nd follow-up tests were (1.77 + .601; 1.87 + .611; 1.92 + .504 & 2. 04+ .591); (1.92+ .660, 1.94+ .651, 2.01+ .546 & 2.23 +.623); (1.73 + .617, 1.83 + .653, 1.90 + .499 & 2.06 + .610) ) of the three perspectives of autonomy respectively.

Table (4): Correlation matrix among level of  knowledge and perceptions of shared governance and the level of autonomy at different periods of measurements (n=78): 

Pre –test = before implementing the educational program.       Post –test = immediately after  program implementation.

Follow-up 1 = after 3 months and Follow-up 2 = after 6 months from implementing the educational program.

**Correlation is significant at the (p < 0.05) and is highly significant at the (p < 0.01) level.

Table (4) shows that, there was statistically significant fair positive correlation between the level of knowledge and perceptions of shared governance before implementing the educational program (pre-test) and at the two follow-up test measures(after 3&6 months from implementing the educational program) with a score of (r (p-value) =.404(0.000); .291(0.010)  & .379 (0 .001) respectively. This table shows also that, there was statistically significant fair positive correlation between both of  knowledge and perceptions of shared governance  level and the level of autonomy over patient care decisions at the time measure before implementing the educational program (pre-test) with a score of (r (p-value)=.310 (0.006) & .304(0.007)) respectively. However, there was no statistical significant correlation found  between either the knowledge or perceptions of shared governance level and both the level of total autonomy and the level of perceived autonomy over  unit operations at all-time measures before and after implementing the educational program (pre, post, 1^st & 2^nd follow-up tests)