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UNC Medical Center Nursing Shared Governance

Nursing Shared Governance at UNC Medical Center 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 Medical Center is based on a councilor format, comprised of five nursing councils (Quality, Research, Professional Development, Professional Practice, and Diversity), with a reporting relationship to the Executive Council. Each Council has a defined mission, purpose and set of bylaws.

Nursing Councils and 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 Surgery Services
  • Chair or designee for each of the Nursing Councils
  • Directors of Nursing
  • Chair of the Nurse Manager 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 initiatives within nursing, 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.
  • Establish yearly goals for diversity initiatives.
  • Collaborate with the Professional Development Council 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 the following:
  • Director
  • Clinical Nurse Managers
  • Nurse Educators

Staff nurse representative from each of the clinical service areas:

  • Surgery Services
  • Oncology
  • Heart Center
  • Medicine Services
  • Women’s Hospital
  • Children’s Hospital
  • Surgical Services
  • Psychiatry
  • Rehab
  • Emergency Department/ Air Care
  • At- large representative from the procedural areas
  • At- large representative from the outpatient clinic areas

Ex Officio Members:

  • Dr. Rumay Alexander, Special Assistant to the CNO for Multicultural Affairs
  • HR representative
  • Nurse Recruitment representative
  • Pastoral Care representative

Membership Privileges:

  • Each Council member/ Clinical service area shall have only one vote (if there is more than one nurse per clinical service area on the Council, there is still one voting member per service).
  • Ex Officio and Ad Hoc members will have no voting privileges.
  • Appointments to the Diversity Council will be for a minimum of a one (1) year period for the first year that the Council is in existence; thereafter the period of appointment will be two (2) years. No more than 50% of the Council will be rotated off each year, including the first year of existence.
  • Election of 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 unit or clinical area representatives.


Officers:

  • The Chair and Co-Chair shall be elected from the membership of the Council. Each will serve one year in the respective position for a total of a two year term (one as Co-Chair, one as Chair). For the first six months of the Council, the Special Assistant to the CNO for Multicultural Affairs will serve as the Chair and a staff nurse will serve in the Co-Chair position.
  • The Nurse Managers will report Council activities to the Nurse Manager Committee on a monthly basis as well as advise the Professional Development Council on management issues.
  • The Director serves as a resource and advises the council on issues that impact the goals and objectives of patient care services and the hospital as a whole.


Duties of the Officers:

  • The Council Chair/ Co-Chair is responsible for reporting to the Nursing Executive Council on a monthly basis.
  • 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 Diversity Council.
  • The Chair will be responsible for the development and submission of an annual report due each December to the Nursing Executive Council.

Committees:
Subcommittees under the Nursing Diversity Council will include:

  • A task force of Ad Hoc committee members shall be formed at the discretion of the Council to meet the needs of the Council or the hospital as a whole.

Meetings:

  • The Nursing Diversity 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 Diversity 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 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 Medical Center.
  • Review, revise, and approve policies, procedures and standards of care.
  • Incorporate nursing research findings into clinical practice in collaboration with the Nursing Research Council.
  • Consult on interdisciplinary issues that impact patient care.
  • Participate in the review of and communication regarding new clinical products and equipment.
  • Provide input for the revision and approval of nursing documentation standards.
  • Consult on the redesign of the hospital patient care delivery model.
  • Represent the nursing perspective in ethical/legal issues.

Membership:
Membership shall include the following:

  • 2 Directors
  • 3 Clinical Nurse Managers
  • 3 Nurse Educators
  • Risk Management Representative
  • Accreditation and Standards Representative

2 staff nurse representatives from each of the clinical service areas:

  • Surgery Services
  • Oncology
  • Heart Center
  • Medicine Services
  • Women’s Hospital
  • Children’s Hospital
  • Surgical Services
  • Psychiatry
  • Rehab
  • Emergency Department/ Air Care
  • At- large representative from the procedural areas
  • At- large representative from the outpatient clinic areas

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 practice issues affect nursing within that setting.

Membership Privileges

  • Each Council member/ Clinical service area shall have only one vote (if there is more than one nurse per clinical service area on the Council, there is still one voting member per service).
  • Ex Officio and Ad Hoc members will have no voting privileges.
  • Appointments to the Practice Council will be for a minimum of a one (1) year period for the first year that the Council is in existence; thereafter the period of appointment will be two (2) years. No more than 50% of the Council will be rotated off each year, including the first year of existence.
  • Election of 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 unit or clinical area representatives.

Officers:

  • The Chair and Co-Chair shall be elected from the membership of the Council. Each will serve one year in the respective position for a total of a two year term (one as Co-Chair, one as Chair). For the first year of the Council, a Director of Nursing will serve as the Chair and a staff nurse will serve in the Co-Chair position.
  • The Nurse Managers will report Council activities to the Nurse Manager Committee on a monthly basis as well as advise the Practice Council on management issues.
  • The Director serves as a resource and advises the council on issues that impact the goals and objectives of patient care services and the hospital as a whole.
  • The Chair will be responsible for the development and submission of an annual report due each December to the Nursing Executive Council.

Duties of the Officers:

  • The Council Chair/ Co-Chair is responsible for reporting to the Nursing Executive Council on a monthly basis.
  • 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 Practice Council.
  • Coordinate the writing of the Practice Council annual report.

Committees:

  • A task force of Ad Hoc committee members shall be formed at the discretion of the Council to meet the needs of the Council or the hospital as a whole.

Meetings:

  • The Practice 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 Practice 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 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 the following:

  • 1 Director
  • 4 Clinical Nurse Managers
  • 2 Nurse Educators
  • NPI Manager/ analyst

1 staff nurse representative from each of the clinical service areas:

  • Surgery Services
  • Oncology
  • Heart Center
  • Medicine Services
  • Women’s Hospital
  • Children’s Hospital
  • Surgical Services
  • Psychiatry
  • Rehab
  • Emergency Department/ Air Care
  • At- large representative from the procedural areas
  • At- large representative from the clinic areas

Ex Officio Members:

  • Hospital QI Department representative
  • Hospital Patient Safety committee representative
  • Director of Accreditation and Standards
  • Risk Management Department representative
  • 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 (if there is more than one nurse per clinical service area on the Council, there is still one voting member per service).
  • Ex Officio and Ad Hoc members will have no voting privileges.
  • Appointments to the Quality Council will be for a minimum of a one (1) year period for the first year that the Council is in existence; thereafter the period of appointment will be two (2) years. No more than 50% of the Council will be rotated off each year, including the first year of existence.
  • Election of 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 unit or clinical area representatives.

Officers:

  • The Chair and Co-Chair shall be elected from the membership of the Council. Each will serve one year in the respective position for a total of a two year term (one as Co-Chair, one as Chair). For the first year of the Council, a Director of Nursing will serve as the Chair and a staff nurse will serve in the Co-Chair position.
  • The Nurse Managers will report Council activities to the Nurse Manager Committee on a monthly basis as well as advise the Professional Development Council on management issues.
  • The Director serves as a resource and advises the council on issues that impact the goals and objectives of patient care services and the hospital as a whole.

Duties of the Officers:

  • The Council Chair/ Co-Chair is responsible for reporting to the Nursing Executive Council on a monthly basis.
  • 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 Quality Council.
  • The Chair will be responsible for the development and submission of an annual report due each December to the Nursing Executive Council.

Committees:

  • Subcommittees under the Nursing Quality Council will include:
  •     Pain Committee
  •     Restraint Committee
  • A task force of Ad Hoc committee members shall be formed at the discretion of the Council to meet the needs of the Council or the hospital as a whole.

Meetings:

  • The Nursing Quality 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 Research 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 Research Council

The Nursing Research Council assists nurses with the implementation of evidence based practice as well as mentoring staff to understand, evaluate, and conduct nursing research.

The purpose of the Nursing Research Council is to:

  • Demystify research for the nursing staff.
  • Maintain a record of all nursing research projects conducted at UNC Medical Center.
  • Provide a forum for education and creative and innovative thinking related to evidence based practice and research.
  • Review and approve all nursing research conducted at UNC Medical Center.
  • Establish the link between evidence based practice and research.
  • Increase UNC Medical Center nursing research visibility within the institution as well as regionally and nationally.
  • Assist nurses with the preparation of research proposals and Institutional Review Board applications.
  • Identify potential nursing research funding sources.

Membership:
Membership shall include the following:

  • 1 Director
  • 2 Clinical Nurse Managers
  • 2 Nurse Educators
  • 1 Health Sciences Librarian
  • Former Chair of the Research Council (Chair from prior year)
  • UNC School of Nursing representative

1 staff nurse representative from each of the clinical service areas:

  • Surgery Services
  • Oncology
  • Heart Center
  • Medicine Services
  • Women’s Hospital
  • Children’s Hospital
  • Surgical Services
  • Psychiatry
  • Rehab
  • Emergency Department/ Air Care
  • At- large representative from the procedural areas
  • At- large representative from the clinic areas

Ad Hoc members:

Other healthcare professionals involved in clinical practice projects will be invited to attend meetings when projects/ requests are being reviewed for approval or when research issues affect practice within that setting.

Membership Privileges:

  • Each Council member/ Clinical service area shall have only one vote (if there is more than one nurse per clinical service area on the Council, there is still one voting member per service).
  • Ad Hoc members will have no voting privileges.
  • Appointments to the Research Council will be for a minimum of a one (1) year period for the first year that the Council is in existence; thereafter the period of appointment will be two (2) years. No more than 50% of the Council will be rotated off each year, including the first year of existence.
  • Election of 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 unit or clinical area representatives.

Officers:

  • The Council Chair and Co-Chair shall be elected from the membership of the Council. The Chair will be a doctorally prepared nurse with an initial three (3) year term.
  • The Director serves as a resource and advises the council on issues that impact the goals and objectives of patient care services and the hospital as a whole.
  • The Nurse Manager will report Council activities to the Nurse Manager Committee on a monthly basis as well as advise the Research Council on management issues.

Duties of the Officers:

  • The Council Chair/ Co-Chair is responsible for reporting to the Nursing Executive Council on a monthly basis.
  • Schedule and facilitate regular meetings.
  • Develop an agenda for each meeting.
  • Ensure that meeting minutes are maintained and disseminated.
  • Promote research activities in nursing newsletters and on the Nursing Web page.
  • The Chair will be responsible for the development and submission of an annual report due each December to the Nursing Executive Council.

Committees:

  • A task force of Ad Hoc committee members shall be formed at the discretion of the Council to meet the needs of the Council or the hospital as a whole.

Meetings:

  • The Research 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 Research 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 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:

  • Assess clinical education needs of staff at all levels and develop strategies to meet those needs in collaboration with the Nursing Practice, Education and Research Department.
  • Participate in the development of competency based orientation programs, including the yearly competency review process in conjunction with the Clinical Practice Council, unit management team and NPER.
  • Assess and evaluate the professional practice model of nursing at UNC Medical Center and participate in the development of educational programs to assist nursing staff in the implementation of the nursing care delivery system.
  • Identify priorities and make recommendations related to formalized staff and leadership development programs.
  • Foster an environment conducive to the advancement and utilization of nursing research in collaboration with the Nursing Research Council.
  • Assess and evaluate the effectiveness of the Professional Advancement Ladder program.
  • Promote the recruitment and retention of the professional nurse and support staff within UNC Medical Center.

Membership:
Membership shall include the following:

  • 1 Director
  • 4 Clinical Nurse Managers
  • 4 Nurse Educators
  • Chair of the Professional Advancement Ladder Committee

1 staff nurse representative from each of the clinical service areas:

  • Surgery Services
  • Oncology
  • Heart Center
  • Medicine Services
  • Women’s Hospital
  • Children’s Hospital
  • Surgical Services
  • Psychiatry
  • Rehab
  • Emergency Department/ Air Care
  • At- large representative from the procedural areas
  • At- large representative from the outpatient clinic areas

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 (if there is more than one nurse per clinical service area on the Council, there is still one voting member per service).
  • Ex Officio and Ad Hoc members will have no voting privileges.
  • Appointments to the Professional Development Council will be for a minimum of a one (1) year period for the first year that the Council is in existence; thereafter the period of appointment will be two (2) years. No more than 50% of the Council will be rotated off each year, including the first year of existence.
  • Election of 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 unit or clinical area representatives.

Officers

  • The Chair and Co-Chair shall be elected from the membership of the Council. Each will serve one year in the respective position for a total of a two year term (one as Co-Chair, one as Chair). For the first year of the Council, a Director of Nursing will serve as the Chair and a staff nurse will serve in the Co-Chair position.
  • The Nurse Managers will report Council activities to the Nurse Manager Committee on a monthly basis as well as advise the Professional Development Council on management issues.
  • The Director serves as a resource and advises the council on issues that impact the goals and objectives of patient care services and the hospital as a whole.

Duties of the Officers:

  • The Council Chair/ Co-Chair is responsible for reporting to the Nursing Executive Council on a monthly basis.
  • 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 Quality Council.
  • The Chair will be responsible for the development and submission of an annual report due each December to the Nursing Executive Council.

Committees:

  • Subcommittees under the Professional Development Council will include:
    • The Professional Advancement Ladder Committee
    • The Nursing Retention Committee
  • A task force of Ad Hoc committee members shall be formed at the discretion of the Council to meet the needs of the Council or the hospital as a whole.

Meetings:

  • The Professional Development 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 Research 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 Careers at UNC Medical Center

If you are interested in learning about nursing career opportunities at UNC Medical Center, please visit our Careers page.

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