Formal Unit-Based Shared Governance to Improve Nurse Engagement

Practice Problem: Nurse engagement is a key driver of nurse satisfaction and nursing retention. Shared governance is an evidence-based practice proven to increase nurse engagement through shared decision-making and results in higher work satisfaction. PICOT: The PICOT question that guided this project was (P) in an ambulatory nursing clinic (I) what is the effect of a shared governance unit-based committee (C) compared to current practice (O) on nurse engagement (T) over 10 weeks? Evidence: An exhaustive literature search resulted in 61 peer-reviewed articles. Eleven studies were included after filtering for duplicates and keywords and evaluating for strength and quality of the evidence. Intervention: The project’s intervention was to implement a unit-based shared governance committee in an ambulatory nursing clinic. The Johns Hopkins EvidenceBased Practice Model for Nursing guided each step, and the ADKAR change model and the three key themes identified in the literature were included in the implementation. Outcome: Two of three measures demonstrated clinical significance including statistically significant results between the pre-and post-intervention Council Health Survey results and a 40% increase in staff engagement on projects implemented. The patient experience survey question “Likelihood of Recommending” score showed improvement at weeks four and eight, however, was not sustained at week twelve and continues to be monitored. Conclusion: This project successfully implemented the evidence-based practice of shared governance by developing a unit-based committee, educating, providing a toolkit of resources, then coaching key stakeholders. As a result, the clinic realized an UNIT-BASED SHARED GOVERNANCE TO IMPROVE NURSE ENGAGEMENT 4 increase in nurse engagement, patient experience, and ownership of the departments’ process improvement. UNIT-BASED SHARED GOVERNANCE TO IMPROVE NURSE ENGAGEMENT 5 Shared Governance Organizations that promote employee engagement realize greater employee satisfaction, higher recruitment, and retention rates, and achieve better patient outcomes (Harter et al., 2002). Hospitals seeking the American Nurse Credentialing Center’s (ANCC) Magnet designation are required to demonstrate outperformance of the national average on a nationally benchmarked nurse engagement survey (ANCC, 2019). This facility’s 2021 Nurse Engagement scores fell below the required threshold; therefore, the leaders are driven to increase engagement scores and improve patient outcomes. Additionally, the facility is experiencing nurse recruitment and retention challenges thus serving as motivation to implement an evidence-based unit-level shared governance (SG) model to engage frontline nurses in these efforts (Kutney-Lee et al., 2016). The University of St. Augustine for Health Sciences (USAHS) blog suggested the magnitude of the current nursing shortage is greater than any previous shortage and is expected to worsen by 2030 (USAHS, 2021). This statistic is corroborated by The Office of Inspector General (OIG) report indicating that 73% percent of Veterans Healthcare Administration (VHA) medical centers are experiencing a severe shortage of nurses (Department of Veterans Affairs, 2021). Finally, the state of California is expected to experience the largest nursing shortage in the U.S. with a projected shortage of 44,500 nurses by 2030 (U.S. HHS, 2017). This DNP Project manuscript will discuss how one medical center in a competitive metropolitan employment market in California implemented SG in an ambulatory nursing unit with the goals of increasing nurse engagement, improving patient outcomes, and achieving Magnet eligibility. UNIT-BASED SHARED GOVERNANCE TO IMPROVE NURSE ENGAGEMENT 6 Significance of the Practice Problem Many of the hospital’s competitors are Magnet-designated making nurse recruitment more challenging, therefore, nurse leaders set a goal to achieve ANCC’s Magnet designation within their strategic plan. The health systems’ local, regional, and national healthcare executives support the pursuit of Magnet designation; however, this facility does not meet the eligibility criteria due to a lower-than-required nurse engagement score. In 2021 the facility’s score fell slightly below the national average and if the hospital does not improve its engagement score, it may not be eligible for the designation. The Magnet designation supports healthy nurse work environments which are essential for nurse satisfaction, retention, and quality patient care (Wei et al., 2018). Shared governance (SG) is an evidence-based practice shown to improve nurse work environments and increase nurse engagement (Kutney-Lee et al., 2016). SG involves frontline staff on organization-wide and unit-level committees led by staff nurses who are trained in methods of decision-making, partnership, and accountability to drive the units’ performance (Swihart & Hess, 2019). Most of the literature on nurse engagement and shared governance features inpatient hospital units because that is what the Magnet program focused on, however, in 2019 ANCC extended the same Nurse Engagement requirement to ambulatory nursing departments, therefore more studies and publications are occurring. A Primary Care nursing unit is considered an ambulatory unit by the National Database for Nursing Quality Indicators (NDNQI) and was identified as having opportunities to improve its nurse engagement scores and patient outcomes. The units’ nurses were eager to implement a SG framework as the structure to guide their improvement projects, and their nurse leaders were supportive. UNIT-BASED SHARED GOVERNANCE TO IMPROVE NURSE ENGAGEMENT 7 All stakeholders agreed that implementing an ambulatory unit-based SG committee would provide the structure needed to increase nurse engagement in decision-making. Moreover, they identified some unit priorities including developing unit-level standards aligned with the Ambulatory Care Nursing Scope of Practice and determining the feasibility of nurses teleworking or having compressed schedules. They also wanted to participate in selecting the departments’ NDNQI nurse-sensitive indicators (NSIs) that will be benchmarked quarterly to meet the Magnet requirement. Achieving and sustaining nurse engagement is important because it impacts nurse retention and recruitment. According to the American Hospital Association (AHA), there are 6,093 hospitals in the U.S. today (AHA, 2022) and only 584 (9.3%) are Magnet-designated and these are considered the top 10% of U.S. hospitals. The Veterans Health Administration (VHA) has 156 medical centers and three have earned the Magnet designation to date. In California 47 of the 344 (13.6627%) are Magnet designated (Michas, 2020) including several in this organization’s market area thus creating a highly competitive nurse recruitment challenge that supports this organization’s rationale to obtain this designation. PICOT Question On an ambulatory nursing unit (P) what is the effect of a shared governance (SG) unit-based committee (UBC) (I) compared to the current practice (C) on nurse engagement (O) over ten weeks (T)? The population of interest was the staff nurses at one of the Community-Based Outpatient Clinics (CBOCs) where adult primary and specialty care are provided Monday through Friday during business hours. This Primary Care nursing unit consists of registered nurses (RNs) and licensed vocational nurses UNIT-BASED SHARED GOVERNANCE TO IMPROVE NURSE ENGAGEMENT 8 (LVNs) who report to a nurse manager. The nurse manager reports to the Primary Care nurse chief who reports to the chief nurse executive. The change to be implemented is the Swihart and Hess (2019) unit-level SG approach to formalize a staff-led committee empowered to improve the units’ work environment and patient outcomes. This unit’s nurses reported they wanted to adopt the unit-based SG model and implement evidence-based practices (EBPs) to improve their nurse engagement and patient outcomes. SG is currently implemented at the organizational level with systemwide councils and committees; however, SG has not been formally established at the unit level. The effect(s) of unit-level SG on nurse engagement is compared to the prior state of a traditional manager-led staff meeting. The impact of this project’s ten-week intervention is measured by the level of nurse engagement determined by the number of nurses actively leading or participating in improvement projects, and the total score on the Council Health Survey (CHS) (see Appendix E) distributed before implementation and 10 weeks post-implementation. The CHS survey was validated in 2017 by 418 participants and was found to have a high internal consistency with Cronbach’s a of .95 overall. The survey’s psychometric properties are currently being evaluated, although preliminary test results are excellent for reliability and validity (Hess et al., 2020). Evidence-Based Practice Framework and Change Theory The Johns Hopkins Evidence-Based Practice Model (JHEBPM) for Nursing and Healthcare Professionals was used to guide the project from start to finish. This tool features nine appendices that were followed to ensure approval, thorough planning, development, and implementation of the SG UBC change project. The Practice UNIT-BASED SHARED GOVERNANCE TO IMPROVE NURSE ENGAGEMENT 9 Question, Evidence, Translation (PET) Guide (see Appendix A) is considered the core of the model as it details the 20 prescriptive steps followed and a Project Schedule tool (see Appendix D) that facilitated planning (Melnyk & Fineout-Overholt, 2019). Prosci’s five-step ADKAR change management model was the project implementation guide. This is an outcome-oriented model, and its advantages include its clear and simple language for change, ease of scaling across large and diverse organizations (Wong et al., 2019), and it had already been adopted by this facility; therefore, leaders and staff were familiar with it. The model has five project milestones: Awareness, Desire, Knowledge, Ability, and Reinforcement. The project participants were surveyed about SG to raise awareness (A) of its absence and inform them of its value to increase their desire (D) to adopt the intervention. Next, the project raised stakeholders’ knowledge (K) of the SG model through a PowerPoint education session (see Appendix B). A council meeting simulation and coaching increased the chairs’ ability (A) to lead and support staff to actively participate in the meetings. These tactics reinforced (R) the project’s aim and achieved the participants desired state of SG, improved nurse engagement, and patient outcomes. The Press Ganey patient experience survey question Likelihood of Recommending score was measured as the initial patient outcome because the data was available for real-time performance

increase in nurse engagement, patient experience, and ownership of the departments' process improvement.

Shared Governance
Organizations that promote employee engagement realize greater employee satisfaction, higher recruitment, and retention rates, and achieve better patient outcomes (Harter et al., 2002). Hospitals seeking the American Nurse Credentialing Center's (ANCC) Magnet designation are required to demonstrate outperformance of the national average on a nationally benchmarked nurse engagement survey (ANCC, 2019). This facility's 2021 Nurse Engagement scores fell below the required threshold; therefore, the leaders are driven to increase engagement scores and improve patient outcomes. Additionally, the facility is experiencing nurse recruitment and retention challenges thus serving as motivation to implement an evidence-based unit-level shared governance (SG) model to engage frontline nurses in these efforts (Kutney-Lee et al., 2016).
The University of St. Augustine for Health Sciences (USAHS) blog suggested the magnitude of the current nursing shortage is greater than any previous shortage and is expected to worsen by 2030 (USAHS, 2021). This statistic is corroborated by The Office of Inspector General (OIG) report indicating that 73% percent of Veterans Healthcare Administration (VHA) medical centers are experiencing a severe shortage of nurses (Department of Veterans Affairs, 2021). Finally, the state of California is expected to experience the largest nursing shortage in the U.S. with a projected shortage of 44,500 nurses by 2030 (U.S. HHS, 2017). This DNP Project manuscript will discuss how one medical center in a competitive metropolitan employment market in California implemented SG in an ambulatory nursing unit with the goals of increasing nurse engagement, improving patient outcomes, and achieving Magnet eligibility.

Significance of the Practice Problem
Many of the hospital's competitors are Magnet-designated making nurse recruitment more challenging, therefore, nurse leaders set a goal to achieve ANCC's Magnet designation within their strategic plan. The health systems' local, regional, and national healthcare executives support the pursuit of Magnet designation; however, this facility does not meet the eligibility criteria due to a lower-than-required nurse engagement score. In 2021 the facility's score fell slightly below the national average and if the hospital does not improve its engagement score, it may not be eligible for the designation. The Magnet designation supports healthy nurse work environments which are essential for nurse satisfaction, retention, and quality patient care (Wei et al., 2018).
Shared governance (SG) is an evidence-based practice shown to improve nurse work environments and increase nurse engagement (Kutney-Lee et al., 2016). SG involves frontline staff on organization-wide and unit-level committees led by staff nurses who are trained in methods of decision-making, partnership, and accountability to drive the units' performance (Swihart & Hess, 2019). Most of the literature on nurse engagement and shared governance features inpatient hospital units because that is what the Magnet program focused on, however, in 2019 ANCC extended the same Nurse Engagement requirement to ambulatory nursing departments, therefore more studies and publications are occurring. A Primary Care nursing unit is considered an ambulatory unit by the National Database for Nursing Quality Indicators (NDNQI) and was identified as having opportunities to improve its nurse engagement scores and patient outcomes. The units' nurses were eager to implement a SG framework as the structure to guide their improvement projects, and their nurse leaders were supportive. All stakeholders agreed that implementing an ambulatory unit-based SG committee would provide the structure needed to increase nurse engagement in decision-making.
Moreover, they identified some unit priorities including developing unit-level standards aligned with the Ambulatory Care Nursing Scope of Practice and determining the feasibility of nurses teleworking or having compressed schedules. They also wanted to participate in selecting the departments' NDNQI nurse-sensitive indicators (NSIs) that will be benchmarked quarterly to meet the Magnet requirement.
Achieving and sustaining nurse engagement is important because it impacts nurse retention and recruitment. According to the American Hospital Association (AHA), there are 6,093 hospitals in the U.S. today (AHA, 2022) and only 584 (9.3%) are Magnet-designated and these are considered the top 10% of U.S. hospitals. The Veterans Health Administration (VHA) has 156 medical centers and three have earned the Magnet designation to date. In California 47 of the 344 (13.6627%) are Magnet designated (Michas, 2020) including several in this organization's market area thus creating a highly competitive nurse recruitment challenge that supports this organization's rationale to obtain this designation.

PICOT Question
On an ambulatory nursing unit (P) what is the effect of a shared governance (SG) unit-based committee (UBC) (I) compared to the current practice (C) on nurse engagement (O) over ten weeks (T)? The population of interest was the staff nurses at one of the Community-Based Outpatient Clinics (CBOCs) where adult primary and specialty care are provided Monday through Friday during business hours. This Primary Care nursing unit consists of registered nurses (RNs) and licensed vocational nurses (LVNs) who report to a nurse manager. The nurse manager reports to the Primary Care nurse chief who reports to the chief nurse executive. The change to be implemented is the Swihart and Hess (2019) unit-level SG approach to formalize a staff-led committee empowered to improve the units' work environment and patient outcomes.
This unit's nurses reported they wanted to adopt the unit-based SG model and implement evidence-based practices (EBPs) to improve their nurse engagement and patient outcomes. SG is currently implemented at the organizational level with systemwide councils and committees; however, SG has not been formally established at the unit level. The effect(s) of unit-level SG on nurse engagement is compared to the prior state of a traditional manager-led staff meeting. The impact of this project's ten-week intervention is measured by the level of nurse engagement determined by the number of nurses actively leading or participating in improvement projects, and the total score on the Council Health Survey (CHS) (see Appendix E) distributed before implementation and 10 weeks post-implementation. The CHS survey was validated in 2017 by 418 participants and was found to have a high internal consistency with Cronbach's a of .95 overall. The survey's psychometric properties are currently being evaluated, although preliminary test results are excellent for reliability and validity (Hess et al., 2020).

Evidence-Based Practice Framework and Change Theory
The Johns Hopkins Evidence-Based Practice Model (JHEBPM) for Nursing and Healthcare Professionals was used to guide the project from start to finish. This tool features nine appendices that were followed to ensure approval, thorough planning, development, and implementation of the SG UBC change project. The Practice Question, Evidence, Translation (PET) Guide (see Appendix A) is considered the core of the model as it details the 20 prescriptive steps followed and a Project Schedule tool (see Appendix D) that facilitated planning (Melnyk & Fineout-Overholt, 2019).
Prosci's five-step ADKAR change management model was the project implementation guide. This is an outcome-oriented model, and its advantages include its clear and simple language for change, ease of scaling across large and diverse organizations (Wong et al., 2019), and it had already been adopted by this facility; therefore, leaders and staff were familiar with it. The model has five project milestones: Awareness, Desire, Knowledge, Ability, and Reinforcement. The project participants were surveyed about SG to raise awareness (A) of its absence and inform them of its value to increase their desire (D) to adopt the intervention. Next, the project raised stakeholders' knowledge (K) of the SG model through a PowerPoint education session (see Appendix B). A council meeting simulation and coaching increased the chairs' ability (A) to lead and support staff to actively participate in the meetings. These tactics reinforced (R) the project's aim and achieved the participants desired state of SG, improved nurse engagement, and patient outcomes. The Press Ganey patient experience survey question Likelihood of Recommending score was measured as the initial patient outcome because the data was available for real-time performance measurement.

Evidence Search Strategy
A literature search was conducted using EBSCO and CINAHL databases using the keywords nursing, shared governance, and nurse engagement. The search was further refined by using filters for peer-reviewed articles with publication dates between 2002 and 2022. Additional keywords included were decision-making, nurse satisfaction, and professional governance. Articles were excluded if they did not include shared governance, decision-making, or engagement. Duplicate articles were eliminated, abstracts were reviewed for PICOT-related subjects, and article reference lists were reviewed for additional articles to be considered for inclusion.

Evidence Search Results
The search yielded a total of 61 articles with 44 remaining after removing duplicates. A review of the abstracts to filter for PICOT-related articles eliminated an additional 19 articles. The remaining 25 articles were reviewed to include only research studies, meta-analyses, or systematic reviews. Five research articles were selected based on PICOT relevance and scored a Good or High-quality rating using the JHEBPM Appraisal Tool (Dang et al., 2022). Further review of the articles' reference lists produced six additional articles related to the PICOT question, resulting in a total of 11 articles for inclusion. The PRISMA flow chart diagram of this evidence search and selection process can be seen in Figure 1  (Good) quality ratings, and support the PICOT question demonstrating SG improves nurse engagement.

Themes with Practice Recommendations
The current body of research answered the PICOT question affirming implementing SG has been found to consistently increase nurse engagement. Within the selected body of evidence, three themes were identified: (1) perceived nurse empowerment increases nurse engagement (Olender et al., 2020), (2) SG education or training increases council effectiveness (Drexler, 2020), and (3) the skills of SG require practice, benefit from coaching, and mature councils demonstrate higher levels of nurse engagement (Di Fiore et al., 2018).

Nurse Empowerment Increases Nurse Engagement
Healthcare organizations that aim for high reliability also aim to increase their staff's engagement in developing and implementing best practices. Staff engagement can be accomplished through the implementation of a SG model that values staff input on unit-level committees so continuous quality improvement can be managed at the point of care. Olender et al. (2020) reported workplace empowerment predicted 30.1% of the variance for work engagement. They also found that empowered employees were more competent at caring for patients which contributed to work engagement. These findings answer the PICOT question affirming that nurses involved in SG report higher levels of engagement (Di Fiore et al., 2018).

Education Improves Shared Governance
The SG model and its four principles of accountability, professional obligation, collateral relationships, and decision-making are not inherently known to nurses or nurse leaders, however, can be established and are best accepted when education is tailored to individual units and their staff. Brull (2015) posited nurse leaders benefit from learning emotional intelligence, transformational leadership, and shared decisionmaking with staff. Drexler (2020) reported staff benefits from learning the scope of SG, how to plan for and conduct meetings, solve disagreements, make decisions, and learn professional role behaviors. Dechairo-Marino et al. (2018) reported educating councils on effective meetings, goal setting, and how to record and report their progress provided value to council members.

Shared Governance Coach
The evidence supports having a SG coach. This can be a chief nurse executive (Dechairo-Marino et al., 2018) or a nurse administrator who supports the structures, processes, and outcomes of SG (Drexler, 2020). Research consistently demonstrated nurses who participate in SG report higher levels of empowerment and engagement (Al-Ruzzieh et al., 2022) and as the SG increased so did empowerment scores (Barden et al., 2011).

Practice Recommendations
The evidence answered this PICOT question; therefore, the Swihart and Hess (2019) SG UBC approach and the three key themes were implemented. The evidence was Level II and III with B grade (Good) quality and provided consistent support for the intervention. The practice recommendations were implemented including a unit-based SG committee and the three themes identified to increase the success of the project: (1) a focus on increasing nurse empowerment as a key driver of nurse engagement, (2) education tailored to the unit's culture, and (3) a SG coach to support the acquisition then the practice of SG skills.

The Setting, Stakeholders, and Systems Change
This project took place at a large integrated Level 1A teaching healthcare system comprised of one large campus and seven primary care community clinics dispersed throughout its metropolitan suburban service area and amongst its 50,000 patients.
Employing over 3,000 employees, including more than 800 nurses, the healthcare system provides comprehensive inpatient and outpatient services, a full-service Spinal Cord Injury/Disease center, extended care programs including long-term care facilities, and an inpatient blind rehabilitation program. The organization maintains accreditations from The Joint Commission (TJC), the American Psychology Association (APA), and the Commission on the Accreditation for Rehabilitation Facilities (CARF). The system conducts research with multiple academic partners in addition to National Institutes of Health (NIH) grant-funded studies, clinical trials, and nursing research. This project involved one of the primary care clinics, its staff of direct care nurses, the nurse manager, the nurse chief, and the chief nurse executive.
The organization is guided by its mission statement which commits to fulfilling President Lincoln's promise to care for veterans, their widows, and their children. Its vision provides the end goal which is "To become the best healthcare system in the country", and its' goals and action plans are based on its values: Integrity, Commitment, Advocacy, Respect, and Excellence (ICARE). The executive leaders intentionally align initiatives to the systems' strategic pillars of safety, experience, access, and quality (SEAQ), and strategic measures are linked to the priorities (Nash et al., 2019). The organization's current culture is considered nimble and resilient with staff eager for improvement. Staff's motivation is due in part to the organization being in its fifth year using LEAN principles and tools for process change and improvement and the second year of its journey to becoming a High-Reliability Organization (HRO) with goals to have zero harm events, top decile staff, clinical, and patient experience outcomes. Finally, the past three years of the COVID-19 pandemic have required significant flexibility of all staff and has left most aware that change is constant and necessary in healthcare.
To meet the organization's Journey to Excellence goal, a primary care clinic selfidentified the need to improve their nurse engagement score and enhance employee satisfaction to meet Magnet eligibility criteria. They were eager to be involved in evidence-based practice decisions and continuous process improvement, to select then improve their nurse-sensitive indicators, nurse engagement, and their patients' Likelihood of Recommending survey score. They had traditional staff meetings led by the nurse manager, however, desired to develop a staff-led unit-based committee to involve more staff in decisions and improvement efforts. The nurse manager confirmed and supported the staff's eagerness to lead and engage in improvements and share accountability.
The sustainment plan is to combine the current manager-led staff meeting with the staff-led unit-based committee and employ the SG principles. The nurse chief and manager will retain standing agenda placeholders to ensure timely communication of administrative information. The co-chairs will develop the remainder of the agenda with staff input and manager approval. The manager will support the committee's two co-chairs by ensuring paid protected time to plan and conduct a one-hour monthly meeting, complete and distribute the meeting minutes, and additional time for action-item followup so projects can be completed.
The project's stakeholders included the chief nurse executive, primary care nurse chief, nurse manager, direct care nurses, providers and other interprofessional staff of the clinic, the Finance department, and the patients receiving care at the clinic. Each has various levels of influence on the project's success with the frontline nurses being the primary stakeholders (see Table 1). After communicating the evidence supporting these practice recommendations, approval to implement the project was obtained from the chief nurse executive, chief nurse, nurse manager, and a frontline nurse eager to lead the Primary Care SG UBC was identified as the committee chair. Collaboration with interprofessional colleagues was needed to help the improvement efforts related to the patient experience outcome. All stakeholders involved in the improvement projects were included in the communications and progress reports to ensure the sustainment of their collaboration and buy-in.
An analysis of the department and teams' strengths, weaknesses, opportunities, and threats (SWOT) was conducted (see Table 2). The strengths and weaknesses identified include the internal factors the team has control over and can impact while the opportunities and threats identify factors the team does not have control over (Virtualstrategist, 2016). This is a micro (unit) level change project though is anticipated to spread to other ambulatory units to continue to increase nurse engagement using the SG UBC model.

Implementation Plan with Timeline and Budget
The project used the ADKAR change theory to achieve three objectives: First, issue the baseline Council Health Survey (CHS), collect, and analyze the data then share the results to raise staff's awareness of the issue. Next, evidence-informed topics were provided to raise the councils' desire to successfully engage in the meetings. The council members were educated to increase their knowledge of SG and their ability to plan and implement a UBC and realize its value. Also, interprofessional colleagues involved in the patients' experience were included to ensure the team could implement the desired improvements. Biweekly coaching sessions were held with the chair, nurse manager, and other council members to reinforce the principles, education, and evidence. Finally, the CHS survey was repeated at Week 9, collected, and results synthesized to determine the projects' impact and significance. Coaching sessions with key stakeholders were continued to ensure sustainment and success.
The budget (see Table 3) indicated this is a low-cost project with one hour of education for seven participants at an average hourly rate of $100 as the only known expense costing $500.00. The SG UBC meetings have combined with the traditional monthly staff meeting, therefore, require ongoing education of new committee members and nurse leaders going forward. With the structures and processes in place to sustain the UBC, it is expected their projects will continue to improve financials, quality, and experience metrics. Sustainment of the project will be handed off to the nurse manager and UBC chairs to collaborate on the agendas, ensure meetings and follow-up actions occur, and improvement projects continue to be implemented, completed, and sustained. The project manager will continue to provide support, education, and coaching regularly. Bi-weekly coaching sessions occurred with the UBC co-chairs to answer questions, problem-solve and provide consultation. The dates and times of the UBC meetings were selected based on a consensus of the key stakeholders' availability. Two UBC meetings were conducted in person. Coaching sessions were conducted virtually using Microsoft Teams due to Covid-19 social distancing requirements and/or for convenience.

Results
The project evaluation design included three measures (1) the difference between the mean score of the 25-item paper Council Health Survey (CHS) (see Appendix I and J) distributed before and after the intervention period, (2) the number of nurses engaged in improvement projects before and after implementing the UBC, and (3) the difference in the departments' patient survey "Likelihood of Recommending" score before, during, and after the intervention (see Figure 2 and Agree (Sullivan & Artino, 2013).
After approval was received from the facilities' local IRB and the University of St.

Augustine's Educational Practice Review Committee (EPRC) the clinics' six full-time and part-time registered nurses voluntarily completed the pre-intervention Council
Health Survey (CHS). The post-intervention survey was issued during the ninth week of the intervention. There were no HIPPA concerns as the surveys did not contain patient data and participants did not provide their names or demographics to ensure anonymity due to the groups' small size. The UBC chair hand delivered and collected both surveys and secured them in a locked office after scanning and emailing them to the project manager for analysis and evaluation. The project manager secured all data on a facilityissued laptop in a locked office to ensure data integrity.
Data from the answered questions were included and there were no unanswered questions to exclude from the analysis. The results of the before and after surveys were entered into an excel spreadsheet and then uploaded into and analyzed by USAHS's Intellectus Statistics program (Intellectus, 2022). A t-test was used to measure the difference between the before and after survey means and determine the significance of the change after the SG UBC was implemented. The result was based on an alpha of .05, t (5) =-4.47, p=.007, and the post-intervention survey mean (M=4.61) was determined to be significantly higher than the pre-intervention survey mean (M=2.48) indicating significance (see Appendix J).
A Shapiro-Wilk test was used to determine the normality of the data distribution.
These results were not significant suggesting the possibility the differences in the before and after surveys were produced by a normal distribution (Razali, 2011). This is likely due to the small number of RNs at this clinic. Increasing the number of participants as the EBP project is spread to more clinics will help resolve this. The results of the t-test validate the clinical significance of the SG UBC intervention and its three elements.
Establishing a staff-led committee that utilized the shared governance principles and tools increased nurse engagement.
The second variable measured was the "Likelihood to Recommend" score on the patient experience survey. The clinic's baseline score (73.26%) was downloaded from the survey vendor's website before the project then at four weeks (73.53%) and eight weeks (93.42%) for comparison. The Top Box score and percentile rank were noted to be higher than the baseline indicating an early positive trend (see Figure 2 and Figure   3). At 12 weeks the score and percentile rank did not sustain the positive trend, however, the measure continues to be monitored for impact.
The third clinical significance measure of nurse engagement is the number of improvement projects led or co-led by clinical RNs (non-supervisory). Before implementing the SG UBC only the nurse manager and the clinic manager-led performance improvement projects. At the end of the ten-week implementation, four RNs were leading, or co-leading improvement projects selected by the committee.
The focus of this EBP project was on clinical significance and realized the desired positive impact of the SG UBC on nurse engagement as expected (Melnyk & Fineout-Overholt, 2019). Improved nurse engagement is found in the difference between the before and after CHS survey mean scores and the number of RN-led projects.

Impact
The project was successful in its aim to increase nurse engagement by implementing formal shared governance at the clinic. The three EBP themes were included; a focus on empowerment, providing education, and providing a coach. During the ten weeks, the clinics' committee elected a chair and co-chair, planned, and met for two official meetings, developed the committee charter, approved a standard communication tool, and agreed on and then launched their initial improvement projects.
One RN changed the process for staff uniform orders to be delivered to the clinic rather than each staff member driving 22 miles to the main campus to pick them up. The new process improves staff satisfaction and returns approximately 30 hours of productive time to the clinic (and patients) annually. Another RN identified the need to find a more efficient process to get vital outside documents into patients' EHRs. The new process reduced the time from receipt of the documents to their being viewable in the EHR from a two-week average to a five-hour average. The new process also reduces the risk of patients experiencing duplication of tests or treatments, prevents potential adverse outcomes, and reduces the workload for nurses and the Health Information Management Systems (HIMS) department staff. Two additional nurse-led projects in process include a request to the Pharmacy and Therapeutics committee to extend specific antibiotic prescriptions beyond the 5-day limit to prevent patients from missing doses, and a request for the hospitals' wound care team to provide virtual consults for clinic patients who present with wounds to avoid treatment delays and travel inconveniences. These two projects are in progress; therefore, their impacts are not yet measurable.
Due to the positive impacts of the UBC; the department permanently changed its monthly staff meetings to include the nurse-led UBC meeting following the manager-led meeting. The project successfully increased nurse engagement and the engaged nurses improved staff satisfaction and patient care with the two completed projects. A limitation was the data collection period for the patient experience surveys. The survey vendor suggested 12 weeks is needed to identify a trend and that data was not available at the time of the final project submission, however, will be included in the project dissemination.
To sustain the committee's success the SG coach will continue attending their meetings and provide education, tools, and assistance to new members upon request.
Next, monthly touchpoints will occur with the coach and UBC chair to document the decisions and improvements made during the first 12 months and report them to the nurse executive and Shared Governance Committee. Finally, the SG coach will facilitate appropriate recognition of the UBC staff, manager, and collaborators for their achievements.

Dissemination Plan
The project results were disseminated internally via a PowerPoint presentation to the Chief Nurse Executive, the clinic's nurse manager, and the SG UBC. The project is scheduled to be presented to the Shared Governance, Magnet Ambassador, and EBP committees. The project manager will also present the project's findings to the USAHS faculty and peers via a poster presentation, and to the facilities' nurses at their Nurses' Week Poster Fair.
Results of the project will be externally disseminated to the healthcare system's national EBP Forum, to SOAR@USA the project repository at USAHS, and an abstract for a poster presentation will be submitted to the annual American Nursing Credentialing Center's (ANCC) national Magnet conference. An abstract for a journal article will be submitted to the Journal of Nursing Administration (JONA). This journal focuses on topics of interest to nurse leaders and often features nursing evidence-based practices that increase nurse engagement and is particularly focused on Magnet designation efforts. Peer review of the scholarly poster, abstract, and manuscript(s) will be obtained from the project managers' EBP preceptor/Chief Nurse Executive before submission.

Conclusion
The EBP change project implemented the Swihart and Hess (2019) SG UBC approach in an ambulatory primary care clinic to improve nurse engagement and patient outcomes. This paper discussed the local and national challenges with nurse recruitment, retention, and engagement, and the value of ANCC's Magnet designation as a strategy to improve these issues. The organization needed to improve its nurse engagement score to achieve Magnet eligibility, therefore, a PICOT question was developed, and the evidence was strategically searched. The evidence was graded, and themes were identified and synthesized to answer the PICOT question. This project discussed and displayed the evidence and then used the JHEBPM model to develop a change project and implemented a formal RN-led shared governance UBC to achieve the desired outcomes.
The Johns Hopkins Evidence-Based framework and Appendix tools were used to guide this project's proposal step-by-step. The project setting was an ambulatory primary care clinic, and the key stakeholders were the Primary Care nursing leadership team, the staff, and the nurse executive. The ADKAR change model was described and employed to develop the project's timeline, budget, implementation, and evaluation plans. Three primary research themes and practice recommendations were synthesized and embedded in the implementation, and the dissemination plan was robust to ensure widespread sharing of the project's outcomes. Given the volume and strength of the evidence, the project manager and stakeholders eagerly implemented the EBP project and realized the positive impacts of a SG UBC on nurse engagement, patient experience, and potential Magnet eligibility.       (1) SharePoint site (2) Unit-specific newsletter (3) Bulletin board (4) Email distribution list (5) Communication tree (6) Staff meetings (7) Operational issues to Nurse Manager (8) Practice issues and changes communicated to Nursing Practice Committee (9) Project Registration Form to Nurse Scientist for unit projects 3. Outcomes a) Project Tracker b) Follow-up c) Quality and safety outcomes i) Nurse-sensitive indicators, e.g.: infections, falls, HAPI, LOS, readmissions (IPEC, NDNQI) ii) Patient satisfaction/experience (SHEP, Press Ganey) iii) Nurse/employee satisfaction (AES, NDNQI RN Engagement) iv) Teamwork

Figure 2
The means of Pre-CHS and Post-CHS with 95.00% CI Error Bars