Nursing Shared Governance at UNC Hospitals is defined as “The decision making model which affords the professional nurse autonomy. It empowers the nursing staff to contribute collectively to the processes related to nursing practice and the nursing work environment.”
The Shared Governance model at UNC Hospitals is based on a councilor format, comprised of five nursing councils (Diversity, Professional Development, Professional Practice, Quality, and Research), with a reporting relationship to the Executive Council. Each Council has a defined mission, purpose and set of bylaws.
Nursing Executive Council
The Nursing Executive Council provides leadership and direction to all Nursing Councils. It serves as a clearinghouse for issues being presented and disseminates them to the appropriate Council for action. In addition, the Nursing Executive Council provides final approval for all Nursing Council recommendations. The purpose of the Nursing Executive Council is to:
- Ensure nursing representation on hospital interdisciplinary committees.
- Collaborate with the CNO to lead the annual goal setting process for the Division of Nursing.
- Delegate initiatives to the appropriate Nursing Council(s).
- Review and approve recommended revisions to all Nursing Council bylaws.
- Provide guidance and support to the chairs and chair-elects of all Councils.
- Develop and review an annual operations calendar for the purpose of planning Council activities.
- Review the annual report submitted by each Nursing Council and provide feedback and direction based on information submitted.
Membership shall include the following:
- Senior Vice President/ Chief Nursing Officer
- Vice President/ Associate Chief Nursing Officer
- Vice President of Peri-Operative Services
- Chair or designee for each of the Nursing Councils
- Directors of Nursing
- Chair of the Nurse Manager Committee
- Chair of the APCAT Committee
Ad Hoc members:
- Representatives of non-nursing areas involved in clinical practice.
- Representatives will attend those meetings when their materials/requests are being reviewed for approval or when education issues affect nursing within that setting.
Membership Privileges:
- Each Council member/ Clinical service area shall have only one vote.
- Ad Hoc members will have no voting privileges.
Officers:
- The Chair is the CNO. In the absence of the CNO the Associate VP or CNO designee shall preside.
Duties of the Officers:
The Council Chair will:
- Schedule and facilitate regular meetings.
- Develop an agenda for each meeting.
- Ensure that meeting minutes are maintained and disseminated.
- Educate staff as to the activities and goals of the Nursing Executive Council.
- Coordinate the writing of the Executive Council annual report.
Meetings:
- The Nursing Executive Council will meet once a month.
- Members must attend at least 75% of yearly meetings to retain their Council membership.
- Inability to attend a meeting must be clearly communicated to the Chair in advance.
- It is the responsibility of the Council member to obtain information from the missed meeting and disseminate this to the appropriate groups.
Quorum:
- 51% of the voting members of the Nurse Executive Council members shall constitute a quorum for all meetings. A consensus decision making process is preferred; when necessary, a motion will be considered approved when passed by a minimum of 2/3 majority vote.
Amendments:
- These bylaws may be amended at any meeting of the Council with a quorum of 2/3 attendance and by a 2/3 majority vote.
- Members shall be notified in writing (14) fourteen days in advance of proposed change.
- Notification shall include present article and section citation and proposed amendment.
- The Nursing Executive Council shall review proposed amendments for final approval.
Nursing Diversity Council
The Nursing Diversity Council provides support for the development and implementation of diversity and inclusion initiatives within nursing and UNC Hospitals, and works to foster a respectful, culturally appropriate environment for patients, families and staff members.
Purpose:
The purpose of the Nursing Diversity Council is to:
- Promote a respectful health care environment that values the incorporation of culturally relevant care for our patients and their families.
- Promote a respectful health care environment that values the differences within diverse communities of staff members, patients, and their families.
- Establish yearly goals for diversity initiatives.
- Collaborate with the Professional Development Council and the Office of Diversity, Equity, and Inclusion to provide a framework for the educational plan in regards to diversity initiatives.
- Develop policies and procedures aligned with the goals and initiatives of the Council.
- Integrate the diversity initiatives with the hospital plan.
- Review data (such as the Employee Opinion Survey, Press Ganey survey, hospital and patient demographics, etc) to assess efficacy of diversity initiatives and incorporate the data to develop action plans.
Membership:
Membership shall include at least one representative from each clinical area:
- Psychiatry
- Emergency
- Peri-Operative
- Surgery
- Procedural
- Outpatient
- Hillsborough
- Oncology
- Heart and Vascular
- Medicine
- Children’s
- Rehabilitation
- Women’s
- Flex/Staffing Office
Membership shall include at least one representative from each administrative role:
- Nursing Directors
- Patient Service Manager
- Clinical Nurse Educator/Clinical Nurse Education Specialist
- Nursing Quality and Research
Membership can include Ex Officio/Ad Hoc members from the following areas:
- UNC School of Nursing
- Human Resources
- Legal Department
- Nursing Quality and Research
- Performance Improvement and Patient Safety Departments
- House Supervisors
- Material Management
- Immediate past Chair of Council
Administrative and Ex Officio/Ad Hoc members shall be included at the discretion of the Council to meet the needs of the Council of UNC Hospitals as a whole.
Membership Privileges:
- Each Council clinical service area member(s) shall have only one vote.
- Administrative and Ex Officio/Ad Hoc members/attendees have no voting privileges.
- Appointments to the Council will be for a minimum of a one (1) year period. No more than 50% of the Council will be rotated off each year.
- Selection of the members shall occur by November of each year; the term of membership will begin in January.
- Members will be responsible for coordinating meetings or reporting activities and disseminating minutes/information to their respective clinical service area.
- Members must attend at least 75% of yearly meetings. Inability to attend shall be clearly communicated to the Chair in advance of the meeting and the member is responsible for the content from the missed meeting.
Officers:
- The Chair and Co-Chair shall be elected from the membership of the Council. Each will serve a one (1) year term in the elected role.
- The Co-Chair will automatically move to the Chair position for their second year beginning in January.
- If the Chair is unable to fulfill their term, the Co-Chair will fulfill the duties of the Chair and a new Co-Chair will be elected.
Duties of the Officers:
- Report monthly to the Nurse Executive Council
- Schedule, plan, and facilitate monthly meetings
- Ensure meeting minutes are accurate, maintained, and disseminated
- Educate Council members to activities and goals of the Council
- Coordinate Council’s submission to annual report
Committees:
Subcommittees under the Nursing Diversity Council will include:
- Subcommittee(s) and/or Taskforce groups of committee members shall be formed or disbanded at the discretion of the Council to meet the needs of the Council or UNC Hospitals.
Meetings:
- Typically, the Council will meet once a month.
- Subcommittee and/or Taskforce groups will be scheduled as needed.
Quorum:
Fifty one percent (51%) of the voting members of Council membership shall constitute a quorum for all meetings. A consensus decision-making process is preferred; when necessary, a motion will be considered approved when passed by a minimum of two-thirds (2/3) majority vote.
Amendments:
- These bylaws may be amended at any meeting of the Council with a quorum of two-thirds (2/3) attendance and by a two-thirds (2/3) majority vote.
- Members shall be notified in writing fourteen (14) days in advance of proposed change(s).
- Notification shall include present article and section citation and proposed amendment.
- The Nursing Executive Council shall review proposed amendments for final approval.
- The Nursing Executive Council shall review proposed amendments for final approval. See “Nursing Executive Council Bylaw Review Process” for details of final approval process.
Nursing Practice Council
The Nursing Practice Council implements and maintains standards of clinical nursing practice and patient care consistent with evidence-based practice and requirements of regulatory agencies.
Purpose:
- Delineate the scope of nursing practice at UNC Hospitals
- Review, revise, and approve policies, procedures, and standards of care
- Incorporate nursing research findings into clinical practice in collaboration with the Nursing Research Council
- Respond to quality improvement findings in collaboration with the Nursing Quality Council
- Consult on interdisciplinary issues that impact patient care
- Participate in the review of and communication about new clinical products and equipment
- Provide input for the revision and approval of nursing documentation standards
- Provide guidance on the nursing patient care delivery model
- Collaborate with the ethics team and legal department on nursing practice issues
Membership:
Membership shall include at least one representative from each clinical area:
- Psychiatry
- Emergency
- Peri-Operative
- Surgery
- Procedural
- Outpatient
- Hillsborough
- Oncology
- Heart and Vascular
- Medicine
- Children’s
- Rehabilitation
- Women’s
- Flex/Staffing Office
Membership shall include at least one representative from each administrative role:
- Nursing Directors
- Patient Service Manager
- Clinical Nurse Educator/Clinical Nurse Education Specialist
Membership can include Ex Officio/Ad Hoc members from the following areas:
- UNC School of Nursing
- Human Resources
- Legal Department
- Nursing Quality and Research
- Performance Improvement and Patient Safety Departments
- House Supervisors
- Material Management
- Immediate past Chair of Council
Administrative and Ex Officio/Ad Hoc members shall be included at the discretion of the Council to meet the needs of the Council of UNC Hospitals as a whole.
Membership Privileges
- Each Council clinical service area member(s) shall have only one vote.
- Administrative and Ex Officio/Ad Hoc members/attendees have no voting privileges.
- Appointments to the Council will be for a minimum of a one (1) year period. No more than 50% of the Council will be rotated off each year.
- Selection of the members shall occur by November of each year; the term of membership will begin in January.
- Members will be responsible for coordinating meetings or reporting activities and disseminating minutes/information to their respective clinical service area.
- Members must attend at least 75% of yearly meetings. Inability to attend shall be clearly communicated to the Chair in advance of the meeting and the member is responsible for the content from the missed meeting.
Officers:
- The Chair and Co-Chair shall be elected from the membership of the Council. Each will serve a one (1) year term in the elected role.
- The Co-Chair will automatically move to the Chair position for their second year beginning in January.
- If the Chair is unable to fulfill their term, the Co-Chair will fulfill the duties of the Chair and a new Co-Chair will be elected.
Duties of the Officers:
- Report monthly to the Nurse Executive Council
- Schedule, plan, and facilitate monthly meetings
- Ensure meeting minutes are accurate, maintained, and disseminated
- Educate Council members to activities and goals of the Council
- Coordinate Council’s submission to annual report
Committees:
- Committees that report to the Council:
- Nursing Policy Committee
- Service line practice groups
- Safety Device Committee
- Membership Liaisons: Products & Equipment; Medication Safety; Pain and Falls Committees
- Subcommittee(s) and/or Taskforce groups of committee members shall be formed or disbanded at the discretion of the Council to meet the needs of the Council or UNC Hospitals.
Meetings:
- Typically, the Council will meet once a month.
- Subcommittee and/or Taskforce groups will be scheduled as needed.
Quorum:
Fifty one percent (51%) of the voting members of Council membership shall constitute a quorum for all meetings. A consensus decision-making process is preferred; when necessary, a motion will be considered approved when passed by a minimum of two-thirds (2/3) majority vote.
Amendments:
- These bylaws may be amended at any meeting of the Council with a quorum of two-thirds (2/3) attendance and by a two-thirds (2/3) majority vote.
- Members shall be notified in writing fourteen (14) days in advance of proposed change(s).
- Notification shall include present article and section citation and proposed amendment.
- The Nursing Executive Council shall review proposed amendments for final approval.
- The Nursing Executive Council shall review proposed amendments for final approval. See “Nursing Executive Council Bylaw Review Process” for details of final approval process.
Nursing Professional Development Council
The Nursing Professional Development Council defines, implements, evaluates and maintains educational standards that promote professional growth, development and ongoing clinical competency for staff and identifies strategies to promote retention of the professional nurse.
The purpose of the Nursing Professional Development Council is to:
- Collaborates with the Nursing Practice and Professional Development Department to address the professional needs of staff at all levels and develops strategies to meet those needs.
- Identify priorities and make recommendations related to formal staff and leadership development programs.
- Foster an environment conducive to collaboration with all shared governance councils to promote the professional development of nursing staff.
- Promote the recruitment and retention of professional nurses and assistive personnel within UNC Hospitals.
- Oversees outcomes and effectiveness of all subcommittees that report to the Professional Development Council.
Membership:
Membership shall include at least one representative from each clinical area:
- Psychiatry
- Emergency
- Peri-Operative
- Surgery
- Procedural
- Outpatient
- Hillsborough
- Oncology
- Heart and Vascular
- Medicine
- Children’s
- Rehabilitation
- Women’s
- Flex/Staffing Office
Membership shall include at least one representative from each administrative role:
- Nursing Directors
- Patient Service Manager
- Clinical Nurse Educator/Clinical Nurse Education Specialist
- Nursing Quality and Research
Membership can include Ex Officio/Ad Hoc members from the following areas:
- UNC School of Nursing
- Human Resources
- Legal Department
- Nursing Quality and Research
- Performance Improvement and Patient Safety Departments
- House Supervisors
- Material Management
- Immediate past Chair of Council
Administrative and Ex Officio/Ad Hoc members shall be included at the discretion of the Council to meet the needs of the Council of UNC Hospitals as a whole.
Membership Privileges:
- Each Council clinical service area member(s) shall have only one vote.
- Administrative and Ex Officio/Ad Hoc members/attendees have no voting privileges.
- Appointments to the Council will be for a minimum of a one (1) year period. No more than 50% of the Council will be rotated off each year.
- Selection of the members shall occur by November of each year; the term of membership will begin in January.
- Members will be responsible for coordinating meetings or reporting activities and disseminating minutes/information to their respective clinical service area.
- Members must attend at least 75% of yearly meetings. Inability to attend shall be clearly communicated to the Chair in advance of the meeting and the member is responsible for the content from the missed meeting.
Officers
- The Chair and Co-Chair shall be elected from the membership of the Council. Each will serve a one (1) year term in the elected role.
- The Co-Chair will automatically move to the Chair position for their second year beginning in January.
- If the Chair is unable to fulfill their term, the Co-Chair will fulfill the duties of the Chair and a new Co-Chair will be elected.
Duties of the Officers:
- Report monthly to the Nurse Executive Council
- Schedule, plan, and facilitate monthly meetings
- Ensure meeting minutes are accurate, maintained, and disseminated
- Educate Council members to activities and goals of the Council
- Coordinate Council’s submission to annual report
Committees:
Nursing Quality Council
The Nursing Quality Council monitors the appropriateness and effectiveness of the care provided by the nursing staff while assessing and ensuring compliance with established standards of care and practice.
The purpose of the Nursing Quality Council is to:
- Develop, revise and approve the annual Nursing Quality Improvement Plan, along with completing an annual evaluation of the effectiveness of the plan.
- Endorse and monitor unit based quality improvement plans.
- Integrate the nursing quality improvement process with the hospital plan to detect trends and patterns of performance that affect more than one department or service.
- Review and evaluate data (NDNQI, unit audit data, benchmarks, etc) and incorporate the data to develop action plans in collaboration with unit practice committees in the department of nursing to ensure quality patient outcomes.
- Monitor and ensure compliance with established state, federal and regulatory standards.
- Collaborate with other disciplines to monitor and evaluate compliance to standards and make recommendations to enhance continuous quality improvement and safety.
- Oversee the process for timely and accurate data submission/reports.
- Monitor and analyze data relative to nursing quality and safety practices seeking opportunities for continual improvement. Evaluate outcomes in conjunction with these initiatives.
Membership:
Membership shall include at least one representative from each clinical area:
- Psychiatry
- Emergency
- Peri-Operative
- Surgery
- Procedural
- Outpatient
- Hillsborough
- Oncology
- Heart and Vascular
- Medicine
- Children’s
- Rehabilitation
- Women’s
- Flex/Staffing Office
Membership shall include at least one representative from each administrative role:
- Nursing Directors
- Patient Service Manager
- Clinical Nurse Educator/Clinical Nurse Education Specialist
- Nursing Quality and Research
Membership can include Ex Officio/Ad Hoc members from the following areas:
- UNC School of Nursing
- Human Resources
- Legal Department
- Nursing Quality and Research
- Performance Improvement and Patient Safety Departments
- House Supervisors
- Material Management
- Immediate past Chair of Council
Administrative and Ex Officio/Ad Hoc members shall be included at the discretion of the Council to meet the needs of the Council of UNC Hospitals as a whole.
Membership Privileges:
- Each Council clinical service area member(s) shall have only one vote.
- Administrative and Ex Officio/Ad Hoc members/attendees have no voting privileges.
- Appointments to the Council will be for a minimum of a one (1) year period. No more than 50% of the Council will be rotated off each year.
- Selection of the members shall occur by November of each year; the term of membership will begin in January.
- Members will be responsible for coordinating meetings or reporting activities and disseminating minutes/information to their respective clinical service area.
- Members must attend at least 75% of yearly meetings. Inability to attend shall be clearly communicated to the Chair in advance of the meeting and the member is responsible for the content from the missed meeting.
Officers:
- The Chair and Co-Chair shall be elected from the membership of the Council. Each will serve a one (1) year term in the elected role.
- The Co-Chair will automatically move to the Chair position for their second year beginning in January.
- If the Chair is unable to fulfill their term, the Co-Chair will fulfill the duties of the Chair and a new Co-Chair will be elected.
Duties of the Officers:
- Report monthly to the Nurse Executive Council
- Schedule, plan, and facilitate monthly meetings
- Ensure meeting minutes are accurate, maintained, and disseminated
- Educate Council members to activities and goals of the Council
- Coordinate Council’s submission to annual report
Committees:
- Committees that report to the Council:
- Restraint Committee
- Nursing Performance Improvement Committee
- Falls Committee
- Skin Committee
- Subcommittee(s) and/or Taskforce groups of committee members shall be formed or disbanded at the discretion of the Council to meet the needs of the Council or UNC Hospitals.
Meetings:
- Typically, the Council will meet once a month.
- Subcommittee and/or Taskforce groups will be scheduled as needed.
Quorum:
Fifty one percent (51%) of the voting members of Council membership shall constitute a quorum for all meetings. A consensus decision-making process is preferred; when necessary, a motion will be considered approved when passed by a minimum of two-thirds (2/3) majority vote.
Amendments:
- These bylaws may be amended at any meeting of the Council with a quorum of two-thirds (2/3) attendance and by a two-thirds (2/3) majority vote.
- Members shall be notified in writing fourteen (14) days in advance of proposed change(s).
- Notification shall include present article and section citation and proposed amendment.
- The Nursing Executive Council shall review proposed amendments for final approval.
- The Nursing Executive Council shall review proposed amendments for final approval. See “Nursing Executive Council Bylaw Review Process” for details of final approval process.
Nursing Research Council
The Nursing Research Council (NRC) engages nurses at UNC Hospitals to generate, utilize, and disseminate nursing research.
The purpose of the Nursing Research Council is to:
- Establish the nursing research agenda for UNC Hospitals in collaboration with nursing leadership and alignment with UNC Hospitals strategic goals.
- Support and advise nurses in their navigation of the research process.
- Provide nurses with educational programs and resources that focus on the research process and evidence based nursing practice.
- Maintain a system for reviewing, tracking, and approving all nursing research at UNC Hospitals.
- Promote the visibility of nursing research at UNC Hospitals and beyond.
Membership:
Membership shall include at least one representative from each clinical area:
- Psychiatry
- Emergency
- Peri-Operative
- Surgery
- Procedural
- Outpatient
- Hillsborough
- Oncology
- Heart and Vascular
- Medicine
- Children’s
- Rehabilitation
- Women’s
- Flex/Staffing Office
Membership shall include at least one representative from each administrative role:
- Nursing Directors
- Patient Service Manager
- Clinical Nurse Educator/Clinical Nurse Education Specialist
- UNC School of Nursing
- Nurse Scientist
Membership can include Ex Officio/Ad Hoc members from the following areas:
- UNC School of Nursing
- Human Resources
- Legal Department
- Nursing Quality and Research
- Performance Improvement and Patient Safety Departments
- House Supervisors
- Material Management
- Immediate past Chair of Council
Administrative and Ex Officio/Ad Hoc members shall be included at the discretion of the Council to meet the needs of the Council of UNC Hospitals as a whole.
Membership Privileges:
- Each Council clinical service area member(s) shall have only one vote, except when voting on research proposals. All eligible reviewers will vote on research proposals.
- Administrative and Ex Officio/Ad Hoc members/attendees have no voting privileges.
- Appointments to the Council will be for a minimum of a two (2) year period. No more than 50% of the Council will be rotated off each year.
- Selection of the members shall occur by November of each year; the term of membership will begin in January.
- Members will be responsible for coordinating meetings or reporting activities and disseminating minutes/information to their respective clinical service area.
- Members must attend at least 75% of yearly meetings. Inability to attend shall be clearly communicated to the Chair in advance of the meeting and the member is responsible for the content from the missed meeting.
- Members must complete The Collaborative Institutional Training Initiative (CITI) web-based ethics training at: https://www.citiprogram.org/.
- Recommended module is (2) Social and Behavioral.
- Members may complete additional, “OPTIONAL” modules or modules that apply to specific research projects in which they are involved.
Officers:
- The Chair and Co-Chair shall be elected from the membership of the Council. Each will serve a one (1) year term in the elected role.
- The Co-Chair will automatically move to the Chair position for their second year beginning in January.
- If the Chair is unable to fulfill their term, the Co-Chair will fulfill the duties of the Chair and a new Co-Chair will be elected.
Duties of the Officers:
- Report monthly to the Nurse Executive Council
- Schedule, plan, and facilitate monthly meetings
- Ensure meeting minutes are accurate, maintained, and disseminated
- Educate Council members to activities and goals of the Council
- Coordinate Council’s submission to annual report
- Maintain the Nursing Research Council log
Committees:
Subcommittee(s) and/or Taskforce groups of committee members shall be formed or disbanded at the discretion of the Council to meet the needs of the Council or UNC Hospitals.
Meetings:
- Typically, the Council will meet once a month.
- Subcommittee and/or Taskforce groups will be scheduled as needed.
Quorum:
Fifty one percent (51%) of the voting members of Council membership shall constitute a quorum for all meetings. A consensus decision-making process is preferred; when necessary, a motion will be considered approved when passed by a minimum of two-thirds (2/3) majority vote.
Amendments:
- These bylaws may be amended at any meeting of the Council with a quorum of two-thirds (2/3) attendance and by a two-thirds (2/3) majority vote.
- Members shall be notified in writing fourteen (14) days in advance of proposed change(s).
- Notification shall include present article and section citation and proposed amendment.
- The Nursing Executive Council shall review proposed amendments for final approval.
- The Nursing Executive Council shall review proposed amendments for final approval. See “Nursing Executive Council Bylaw Review Process” for details of final approval process.
