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Shared Governance as an Antecedent of Intention to Leave and Job Satisfaction among Nurses in Level 3 Government Hospitals in Region III, Philippines

Background: Shared governance may be considered as both a guideline and a technique that allows nurses to have a say in decision-making measures. Rather of assigning full accountability to one nurse, it is distributed to each group member. In the face of high attrition, healthcare officials are still considering strategies to improve nurse job satisfaction and retention. Aim: The purpose of the study is to explore shared governance as an antecedent of intention to leave and job satisfaction among nurses in Level III government hospitals in Region III, Philippines. Materials and Methods: Quantitative descriptive type of research was used. A total of 806 nurses across six (6) Level III government hospitals in Region III, Philippines participated in the study. Three instruments were utilized namely: 1) Shared Governance was measured using the Index of Professional Nursing Governance by Hess (1998) used in the study of Wilson (2013); 2) Intention to Leave questionnaire by Mohammed and Mohammed (2013) used in the research of Ahmed, Abdelwahab, and Elguindy (2017) and 3) Job Satisfaction questionnaire by Mueller


Introduction
In recent years, nursing profession earned an augmenting influence in all the attributes of healthcare industry. It is critical that every nurse promotes and develops leadership skills early in his or her career. Nurses who demonstrate great leadership and management will be in a dynamic position to contribute to the progress of other staff members and enable them to improve as competent practitioners [1,2].
Empowering nurses utilizing the concept and structure of nursing professional practice models via shared governance is thought to be potentially beneficial in terms of retaining nurses, satisfying work experience, and constantly improving patient care results. Leaders need to exert more of their selves to build workplace that establishes the physical-mental and well-being of nurses. Selecting the appropriate kind of leader is critical to this process. Nurses should have the capacity to work within hospital in which everybody is being considered to respect and acknowledge for their big contribution to patient-centered care [3]. A competent leader is one of the durable and powerful instruments for enhancing nurse retention. Especially nurse leaders, they are in a point to be the transformative agents for having and making hospitals where nurses desire to stay.
Shared governance may be considered as both a guideline and a technique that allows nurses to have a say in decision-making measures. Rather of assigning full accountability to one nurse, it is distributed to each group member. Shared governance has been used in healthcare institutions, most notably in nursing services. Nurses accept responsibility for their actions, participate in decision-making, explore and evaluate associated topics, examine differences with each point of view, and are active participants in hospital administration [4].
It is also reiterated in a study that the nurse has a challenging career, having days caring for patients while working in long hours with lacking staffs. After many years of service and reaching the point of burnout, many nurses are now questioning whether they should have chosen the nursing profession in the first place. In the face of high attrition, healthcare officials are still considering strategies to improve nurse job satisfaction and retention. To help avoid attrition and improve retention, hospital management should identify characteristics that may reduce job satisfaction as well as the relationship between job satisfaction and nurse intention to leave which is a part of turnover [5].
Nurse turnover has a negative impact on the capacity to come up with patient needs and promote excellent care, which might be developing more stress to other nurses because of added workloads. This may affect some changes or alter in work performance towards to their duties leading in decreased work satisfaction, reduced productivity, and leaving the organization [6]. Intention to leave the organization especially nursing profession has turned into a workforce problem and an immense challenge to nursing service administration nowadays in the health industry. Ongoing manpower fluctuation in locally and internationally is raising questions on the antecedent of nurses' turnover on the satisfaction of the nurse, quality patient care, and system costs [7,8].
Through the aforementioned statements, the researchers aspired to focus on the study of shared governance as an antecedent of intention to leave and job satisfaction among nurses. Specifically, the aim of the study was to explore shared governance as an antecedent of intention to leave and job satisfaction among nurses in Level III government hospitals in Region III, Philippines. It is hoped that this study will serve and contribute towards quality improvement of nursing leadership and management.

Methods
The study utilized a quantitative descriptive type of research which aims to observe, describe, and document aspects of a situation as it naturally occurs and sometimes to serve as a starting point for hypothesis generation or theory development [9,10]. Six (6) level 3 government hospitals across the Region III, Philippine served as locales for the study. These different institutions were all teaching and training hospitals offering critical and intensive care unit, a functional and specific form of treatment, departmentalized, and specialized in technical equipment and in managing nursing care. They have all services catered by the Level 2 hospitals. The respondents of this research study covered 806 nurses out of 900 nurses who comprised the nursing service with 89.5% retrieval rate. The following were the inclusion criteria: 1) duly licensed professional nurse 2) engaged in a level 3 government hospital of Region III. 3) Permanent or plantilla position 4) designation was from the staff nurse up to assistant chief nurse and 5) willing and who agreed to participate. Excluded were those 1) contractual or job order status 2) chief nursing officer who is a member of executive committee of the organization and 3) nurses who are unable to meet the inclusion standards. Multi-stage census and purposive sampling were employed in choosing the respondents of the study. Three standardized tools were utilized for this paper namely: 1) Shared Governance was measured using the Index of Professional Nursing Governance by Hess (1998) [14,15]. Permission to use instruments were secured from main authors. Our Lady of Fatima University-Institutional Ethics Review Committee (OLFU-IERC) (version 2020-RDIC1-30072) did ethical clearance. Communication letters were prepared for conveying the research details and sent to the respective medical center chief/ chief of hospitals of Level 3 government hospitals in Region III through the research department then to the nursing service offices for approval. The procedure of recruiting participants and in getting their informed consent was through orienting them individually. The respondents agreed to take part in research and were furnished with consent forms, signed and accomplished. Upon completion, the researchers were personally present to discuss the details comprehensively. Frequency and percentage were used for the profile and Cramer's V was utilized to explore if shared governance as considered antecedent of intention to leave and job satisfaction among nurses. Table 1 presents the profile of the respondents. In terms of age, there were 248 or 30.8% whose ages were 31-35. About 209 respondents (25.9%) were age 36-40 years old. In addition, 195 respondents (24.2%) were 26-30 years old; 98 respondents (12.2%) were 20-25 years old; 39 respondents (4.8%) were 41-45 years old; 13 respondents (1.6%) were 46-50 years old, and lastly, 4 respondents (0.5 %) were 51 years old and above. This indicates that in this study, majority or about 248 (30.8%) of the respondents belonged to the age group of 31-35 years old. This distribution was consistent with the current situation of hospitals wherein most of the nurses belong to the 31-35 years old population.

Results
In the context of sex, majority of the respondents were female with 454 respondents (56.3%) and 352 male respondents or 43.7%. In terms of highest educational attainment, 526 or 65.3% of the respondents were bachelor's degree holders, with earned units in master's degree were 238 (29.5%), and 42 or 5.2% of the respondents were master's degree holders.
Concerning the length of clinical experience, majority of the respondents or 247 (30.6%) were 11-15 years in service; 201 (24.9%) were 16-20 years; 188 (23.3%) 6-10 years, 114 (14.1%) 1-5 years; 39 (4.8%) 21-25 years; and 17 or 2.1% have 26 years and above clinical experience. In view of designation, majority of the respondents or 554 (68.7%) were head/senior nurses; 159 or 19.7% were staff nurses; 65 (8.1%) were nurse supervisors; 22 (2.7%) were nurse managers; 3 (0.4%) were assistant chief nurse; 2 (0.2%) were training officers; and 1 or 0.1% was a nurse researcher, meaning most of them are in Nurse-II plantilla position. In the terms of area of assignment, majority were assigned in pediatric ward with 184 respondents or 22.8%; 171 or 21.2% were in the medicine ward, 142 or 17.6% were in the obstetrics-gynecology ward; 123 or 15.3% were in the surgery ward; 56 or 6.9% were in the emergency room; 42 or 5.2 % were in the intensive care unit; 33 or 4.1% were in the operating room,; 28 or 3.5% were assigned in the nursing service office; 14 or 1.7% were in the outpatient department; and about 13 or 1.6% were assigned in the dialysis unit. Table 2 presents the shared governance as an antecedent of the level of intention to leave and job satisfaction. With reference to 'intention to leave', the computed Cramer's V for 'preference of nurses to continue working in the hospital' (V=0.000), 'Nurses preference to stay in the hospital' (V=0.020) and 'return to work in the hospital after leaving for a certain period '(V=0.000) were considered not antecedent of shared governance as evidenced of the qualitative description of "no or very weak association". While, with reference to "job satisfaction", the computed Cramer's V for interaction opportunities (V=0.062), scheduling (V=0.000), professional opportunities (V=0.000), balance of family and work (V=0.000), praise and recognition (V=0.067) and extrinsic rewards (V=0.057) were considered not antecedent of shared governance as evidenced of the qualitative description of "no or very weak to weak association". On the other hand, the computed Cramer's V for control and responsibility (V=0.115) was considered antecedent of shared governance as evidenced by the qualitative description of "moderate association".

Discussion
It was found out that shared governance is not considered as the antecedent of the intention to leave among nurses. The result implies that shared governance in the tertiary government hospitals in Region III, Philippines was well practiced. Shared governance is a type of nursing management that allows clinical nurses more authority over their professional practice while also giving them more influence over the resources to sustain it [16]. Attitudes, individual actions, and beliefs influence transdisciplinary professional collaboration in shared governance leading to empowerment among staff and co-workers [17]. As such, empowering nurses and involving them to hospital decisionmaking were one of the key components to feel that nurses are being valued in their workplace and that retention and intention to leave decreases. It supports the study of Hatfield (2017) that the greater engagement of top management to implement shared governance on their respective organization, there will be significantly low probability of intention to leave of the employees [18]. In the study of Tummers et al. (2013) they enumerate important reasons for nurses' intension to leave, first, not enough growth and career advancement, and second, an unfavorable working environment heavily affects the intention to leave [19].
Moreover, it was revealed that shared governance is not considered as antecedent of the job satisfaction among nurses except for the control and responsibility variable. The result implied that tertiary government hospitals in Region III, Philippines were committed in implementing shared governance in nursing administration except for control and responsibility, which involves participation in organizational decisionmaking. Professional practice environment that embraces shared governance may serves as useful intervention to promote job satisfaction with their employees. It supports the study of Andrew (2014) that the more our nursing leaders demonstrates shared governance in nursing leadership, the greater job satisfaction will implicate on nurses. Through maintaining shared governance employees finds their work environment gratifying, stimulating, and motivating [20]. Lewis (2017) added that healthcare organizations that incorporate the spirit of shared governance could have a valuable intervention to promote optimal employees and patient's outcomes [21]. Nurses should be given more influence over their working conditions, what goes into their work environment, and the degree of responsibility. Strengthening nurses' attendance at regular meetings and/or unit or organizational meetings, are critical if these nurses are to engage in decision-making that may affect nursing care, including their practice; similarly, assessment and evaluation should be done on a continuous basis. As a result, schedule flexibility, the ability to work straight days, weekend day off flexibility, and other compensations should be implemented.

Conclusion
Shared governance in healthcare institution should be welcome in terms of communication among their constituents. Seeking input, empowering, and recognizing them as part of decision-making process can boost the confidence among the different components of the healthcare institution. As such, nurses at all levels of the organization should govern and participate in decisions that influence their practice; thus, this allows them to have greater independence and control over their practice leading to retention of job satisfaction and stay in the institution.