Introduction

Nurses play a decisive role in the transformation processes of Healthcare Organizations (HCOs) and in the development of the healthcare delivery system for the population. Achieving quality standards requires strong yet flexible structures aimed at standardizing care practices, protecting individuals, and upholding the dignity of the profession to ensure excellence in care (^{Order of Nurses} [OE], 2011).

The care practice environment is fundamental to the success of healthcare systems and is directly linked to the quality of care, safety, effectiveness, and efficiency of Organizations (^{Carvalho & Lucas, 2020}). Improving healthcare quality involves achieving better patient outcomes, both in terms of well-being and satisfaction with the care received, within a well-organized system. This, in turn, demands the full involvement of professionals and the HCO (^{Segundo, 2018}).

The concept of Clinical Governance (CG) is an important issue related to the coordinated delivery of high-quality patient care (^{Braithwaite & Travaglia, 2008}). ^{Barden et al. (2011}) add that CG, in the context of Nursing, corresponds to the processes and structures that promote autonomy, control, and supervision of practices within an HCO. Thus, CG is a participatory system in which HCOs are responsible for the continuous improvement of the quality of their services and outcomes.

However, transitioning from a centralized governance model, structured along vertical lines of accountability, to increasingly decentralized systems with multiple actors and levels of authority presents complex challenges for healthcare governance in modern health systems (ibid.).

The performance and interactions of CG are shaped by strategic leadership and management. Therefore, a reference framework should be established to explicitly define how healthcare system actors are expected to perform and interact (ibid.).

In light of this, a research question was formulated using the PIO method - Participant (Type of participants); Intervention (Type of Intervention); Outcomes (Type of Results):

"What is the impact of implementing the CG model in Nursing on nurses' care practices?"

Thus, through this systematic literature review, we aim to analyze whether there is evidence that CG in Nursing impacts nurses' care practices.

1. Theoretical framework

The dynamics of a Health System are complex. It should be based on the interaction and balance of various stakeholders: leadership and governance, human and material resources, knowledge, financing, suppliers, information, infrastructure and service delivery, population, principles and values, as well as objectives and outcomes.

^{Leone (2011}, p. 16) defines Healthcare Organizations (HCOs) as "dynamic, living, and complex structures that coexist with uncertainty, contradiction, and constant conflict." Managing these organizations is, therefore, a challenge-not only due to the complexity, differentiation, and specificity of the sector but also because of the "web" of stakeholders, market logics, governance models, and ongoing social changes. Sustainability and efficiency, as key elements, are constantly in focus, particularly in our country, where the health system faces chronic economic, financial, and organizational difficulties.

The concept of governance originates from the Latin term “gubernare”, which means to govern, direct, or guide, and can be defined as the process of collective action that organizes the interaction between human resources, dynamics, processes, and both formal and informal rules (^{Pierre & Peters, 2000}).

Clinical Governance (CG) is based on fundamental pillars that pave the way toward a philosophy of management aimed at maximum quality. Only through this approach can we align with patient expectations. According to ^{Biscaia Fraga (2014}), the seven key pillars on which CG must be based are patient and population engagement, risk management, clinical audit, human resource management, education, continuous training, personal and professional development, clinical effectiveness, and clinical information.

CG aims to achieve the best management of individual practice as a means of providing high-quality care.

Nursing care develops under the influence of several factors that can alter its quality and efficiency, particularly the organizational climate in which care is delivered (^{Amaral et al., 2015}; ^{Kutney-Lee et al., 2016}). According to ^{Guerra et al. (2021}), compared to other healthcare professionals in the hospital setting, nurses provide more concrete information on organizational performance indicators, given their broad scope of practice, which puts them in contact with most organizational factors.

In healthcare, the term governance is used in discussions about best management practices that can be adopted to improve care delivery.

The Regional Support and Monitoring Team for Primary Healthcare of the Lisbon and Tagus Valley Regional Health Administration, in 2017, defined CG as "a system of knowledge, attitudes, and piloting practices at individual, team, and service levels to achieve results in terms of effectiveness with equity (health gains) for individuals, families, and communities, involving everyone through the improvement of the quality of healthcare processes and health intervention" (p. 4).

2. Methods

As a starting point for this systematic literature review, the following question was formulated using the PIO method - Participant (Type of participants), Intervention (Type of intervention), Outcomes (Type of results) (^{Melnyk et al., 2005}):

"What is the impact of implementing the CG model in Nursing on nurses' care practices?"

Since this is a systematic literature review and, therefore, a study that uses public data, ethical committee approval was not required. However, all authors have been duly cited.

2.2 Data collection instruments

The search for scientific articles was conducted in March 2023, covering a chronological range from 2018 to 2022. Prior to the search, some filters were applied in addition to the time frame, such as open-access articles with full text available in English, Portuguese, or Spanish, resulting in a total of 128 articles.

Duplicate articles were removed, and the initial pre-selection was based on title and abstract analysis, considering all articles relevant to the topic. Subsequently, the following inclusion and exclusion criteria were applied:

Inclusion criteria:

Articles that study Clinical Governance (CG) in Nursing and its impact on nurses' care delivery.

Exclusion criteria:

Articles that do not study CG in Nursing.

Articles that do not examine the impact on nurses' care delivery.

After applying these criteria, 8 articles were selected (Figure 1), following the PRISMA 2020 flowchart. PRISMA 2020 was designed primarily to describe systematic reviews evaluating the effects of health interventions (^{Page et al., 2021}).

Figure 1 Flowchart: Article selection process 

3. Results

The selected articles were analyzed based on their objectives, population/sample, study design, and conclusions/results. A global analysis of the included articles provides evidence that Clinical Governance (CG) in Nursing positively impacts nurses' care practices in the following dimensions: improved quality of care, greater professional autonomy, better coordination between healthcare services, and increased job satisfaction. Therefore, Table 1 presents the articles included in this review and establishes a

connection with the mentioned dimensions and CG axes.

4. Discussion

The descriptive study conducted by ^{Koroglu Kaba & Ozturk (2022}) aimed to assess nurses' perception of the CG climate after applying a Clinical Governance Climate scale to a sample of 315 nurses. The findings indicate that nurses with more years of experience tend to have a more negative view of the organizational environment compared to younger nurses, as the latter place greater emphasis on professional relationships due to inexperience. Additionally, nurses' roles affect their perception of the CG environment - nurses in management positions have a more positive view of governance compared to operational nurses, as they are more involved in quality improvement and risk management activities.

Moreover, nurses who voluntarily choose their work unit report higher satisfaction with their service, manager, and profession, contributing positively to the governance environment. Motivated professionals foster a positive organizational environment, leading to more effective and efficient care delivery that ensures patient safety. On the other hand, nurses who are satisfied with the institution where they work communicate more positively with their peers, using their skills and competencies to enhance the quality of care.

The number of patients assigned to each nurse is another key point highlighted in the study. Nurses who provide care to a large number of patients per shift tend to have a negative perception of the governance climate due to the increased likelihood of errors and risk management challenges.

To enhance the governance environment in hospitals, nurses should be encouraged to participate in quality and risk management studies, planning, and integration efforts. This fosters a more participatory and democratic work environment, especially when opportunities for teamwork are provided. Balancing nurses' workloads ensures they have a "voice" in safe decision-making, leading to patient care based on stronger foundational principles.

Relating these study findings to the Clinical Governance (CG) pillars, we observe a direct link between risk and human resource management, which ultimately translates into greater job satisfaction and improved quality of care.

The cross-sectional study by ^{Hu et al. (2021}) reinforces that a positive work environment attracts and retains the best healthcare professionals. In this study, Chinese hospitals sought to enhance the work environment by introducing a nurse retention program. Hospitals with Shared Clinical Governance (SCG) models were compared to those without. The study also highlights Magnet and non-Magnet hospitals. The Magnet concept is regarded as the highest and most prestigious credential in the healthcare sector. A Magnet-based organization focuses on creating a positive work environment, increasing autonomy in practice, shared decision-making, and structural empowerment. This, in turn, boosts nurses' satisfaction and motivation while reducing turnover rates.

Magnet hospitals implementing the SCG model improved the work environment for nurses. Additionally, it is crucial to empower nurses and involve them in decision-making regarding clinical practices, as this contributes to professional empowerment, job satisfaction, and autonomy.

The study further emphasizes that nurses should be involved in decisions related to job positions, promotions, salaries, and benefits to strengthen the governance model. From a CG perspective, human resource management plays a crucial role in improving care quality, autonomy, and job satisfaction.

In Australia, ^{Forsdike et al. (2018}) conducted a multiple case study to understand Clinical Governance in general practice. Nurses working within informal and flexible CG structures reported greater autonomy than those in more formalized governance frameworks. An organizational culture based on flexible structures rather than strict hierarchies may be the key to success.

These findings confirm that clinical effectiveness-meaning that nurse managers follow an evidence-based management model, such as transformational and transactional leadership models-leads to greater professional autonomy.

The experimental study by Duan et al. (2022) aimed to examine the application of the Plan - Do - Check - Adjust (PDCA) cycle in nurses’ work and explore its influence on work efficiency, enthusiasm, and the nursing team’s cooperation capacity. From January 2019 to January 2021, nurses were divided into two groups of 80 nurses each: a control group following conventional management models and an experimental group under the influence of the PDCA cycle. Nursing quality, teamwork capacity, quality care indicators, nurse satisfaction indicators, issues in nursing document quality management, and nurses' enthusiasm were compared between the control and experimental groups.

The PDCA cycle method proved to be one of the strongest and most efficient structures for a healthcare team. Comparing the two groups of nurses in the study, the experimental group demonstrated better results: higher-quality nursing care, strengthened teamwork capacity, improved efficiency and enthusiasm in care delivery, increased professional motivation, enhanced patient satisfaction, and greater external visibility for the HCO.

The Clinical Governance (CG) method through the PDCA cycle is seen as a strategic management model focused on problem-solving, root cause analysis, and the development of improvement strategies.

This study confirms that decision-making processes and management models such as the PDCA cycle lead to improved care quality and better coordination between healthcare services, impacting the pillars of clinical effectiveness and patient and community engagement.

^{Kanninen et al. (2021}) aimed to assess Clinical Governance in Nursing at a university hospital in Finland and validate the Professional Nursing Governance Index. To achieve this, they conducted a cross-sectional study with 419 nurses. In this study, nurses with over five years of experience (28%-44%) stated that the governance style in their organization was traditional, meaning nurses had little to no impact on decision-making.

However, a substantial proportion (12%-30%) of nurses with specialties or management positions reported that decision-making power in nursing-related matters was delegated to the nursing team, while the organization's administration played only a minor role. As a result, these nurses played a crucial role in transforming the work environment and developing system improvement initiatives. This highlights a clear need to drive progress toward empowerment through interventions tailored to specific organizations.

The results indicate that nursing professionals have access to information, influence over practice-support resources, control over their practice, and the ability to set goals and resolve conflicts. This is encouraging for Finnish healthcare as a whole and particularly for the university hospitals included in the study, which are actively developing their management style while striving for Magnet status.

The study further reinforces the need for continuous evaluation of professional Clinical Governance to monitor governance changes, adjust improvement interventions, and ensure that all nurses proactively reflect on and engage with changes. Establishing effective Clinical Governance requires an intrinsic effort from nurse managers, a sense of leadership in decision-making, and a strong commitment to empowering their professionals.

This study highlights that education, continuous training, and personal and professional development contribute to improved care quality and greater job satisfaction.

^{Abd-El Aliem & Hashish (2021}) conducted a descriptive correlational study to determine the relationship between nurse managers' leadership practices, organizational resilience, and their connection to nurses' work in a university hospital in Saudi Arabia. The study included a sample of 60 nurse managers and 211 general care nurses. Two study hypotheses were proposed: 1- “There is no significant effect of nurse managers’ leadership on nurses’ care practices and organizational resilience.” 2- “There is a significant effect of nurse managers’ leadership on nurses’ care practices and organizational resilience.”

It became evident that nurse managers' leadership is essential for the structural environment of the nursing team. They are recognized for their ability to guide others into action, pave the way, and challenge processes. This is attributed to the authority they exercise, but combined with their skills and talents expanded through personal and professional experience, they develop self-control in their management functions. They aim to be role models for team members who trust their experience and abilities.

Thus, managers should distribute power, oversee, and empower the team to face organizational changes and challenges in the healthcare system. Additionally, for the nursing profession to continue progressing as a discipline, they must inspire creativity, promote self-sufficiency, encourage professional growth, and reward excellence in care.

The need for resilience among nurses within an HCO is also highlighted, as it can mitigate the negative impact of environmental stressors in professional practice and improve patient care. Engagement in services was identified as an important factor related to organizational justice, value and respect, leadership performance, decision-making practices, team relationships, and job characteristics. Nurses value their profession and the opportunity to make a difference in patients' lives, which enhances their sense of commitment and engagement with their work and the organization. This engagement strongly correlates with outcome indicators, organizational commitment, job satisfaction, turnover, and absenteeism. It is important to note that nurses seek accessibility in their leaders. Investing in nurses' well-being generally yields a higher return on investment, as their motivation drives clinical practice progress, enhancing patient outcomes. The leadership practices of nurse managers demonstrated a predictive power of 43% in professional resilience variation and 40% in work engagement in the study.

Shared Clinical Governance (SCG), participatory decision-making, open communication, shared vision, self-reflection, and a fair and respectful work environment that conveys appreciation and gratitude to nurses are strategies that enhance leadership effectiveness, foster positive work attitudes among nurses, and help achieve desired outcomes. Learning opportunities should be created to help nurses become more resilient and assertive in patient care. Likewise, leaders are expected to cultivate well-being cultures and implement evidence-based continuous improvement programs.

A governance model based on the pillars of clinical effectiveness, education, continuous training, and personal and professional development enhances care quality, autonomy, and job satisfaction.

Thus, the study by ^{Abd-El Aliem & Hashish (2021}) reinforces the hypothesis that nurse managers' leadership has a significant impact on nurses' care practices and organizational resilience. Although the study does not explore any specific governance pillar in detail, it highlights its positive impact on care quality improvement.

^{Brennan & Wendt (2021}), in their descriptive study, emphasize SCG, providing an exemplary description of how to improve this governance model in a community hospital. After evaluating the results of a gap analysis, they incorporated guiding frameworks such as action planning processes, the PDCA cycle, and Lean methodologies to increase nursing team engagement in SCG. The core principles of SCG include ownership, responsibility, empowerment, team training, leadership, innovation, autonomy, and equity in practice. However, the lack of a clear vision of a viable SCG model often leads to difficulties in implementation, integration, and sustainability within organizations.

The most common benefit of SCG is empowerment. Crucial factors include creating and supporting processes that foster innovation while preventing stagnation, stimulating growth, and generating valuable and productive outcomes. As a result, the nursing team perceives the changes affecting them as part of any process in which they are involved. The discussion of SCG in this article describes its implementation in a suburban community hospital with approximately 200 beds and around 550 nurses, 30 of whom are part of the SCG council.

After analyzing gaps and initial results, suggested changes included more frequent meetings, the adoption of a formalized action plan based on the PDCA cycle, and the integration of additional improvements. The PDCA cycle provided a sequential step-by-step process to assess, analyze, strategize, set goals, plan, and evaluate effectiveness. These steps facilitated greater engagement and understanding of the improvement process, leading to productive and meaningful outcomes. The SCG process is based on partnership, equity, responsibility, and ownership-key elements for success.

This study again integrates the pillar of education, continuous training, and personal and professional development, as well as clinical effectiveness, which contribute to improved care quality and increased job satisfaction.

The final study in this systematic literature review once again highlights the importance of SCG. ^{Nishio et al. (2021}), in their exploratory, cross-sectional, and quantitative study, aimed to evaluate the nursing service management model from nurses' perspectives, based on a sample of 518. In a traditional governance model, hospital administration holds greater influence over decision-making within the organization. However, shared decision-making represents significant progress toward excellence.

The study asserts that the nursing governance model is undergoing an important maturation phase, where nursing leadership experiences can foster meaningful cooperation in creating and adapting healthy work environments for best professional practices. Incorporating changes based on scientific community studies is a priority for managers seeking to improve structures and management processes while guiding and empirically measuring outcomes. Thus, practicing leadership and management based on clinical effectiveness-grounding practice in the best scientific evidence-enables the delivery of higher-quality care.

Conclusion

Clinical Governance (CG) is the process through which healthcare organizations take responsibility for the continuous improvement of their service quality and outcomes, involving all members of the healthcare team to achieve this goal.

The concept of CG represents a contemporary management approach that includes elements such as participatory democracy, co-management, rule of law, transparency and accountability in management, responsibility, commitment-driven approaches, equality for all, efficiency, and strategic vision. It is a prevailing trend, especially in discussions about best leadership and management practices that can be adopted to enhance patient care.

One of the fundamental principles of hospital governance is the participation and involvement of nurses in management and decision-making processes. This requires strong engagement in care management, significantly impacting the coordinated delivery of high-quality patient care. In recent years, the specific requirements for developing effective CG have begun to be identified.

This systematic literature review revealed evidence that CG in nursing has a positive impact on nursing care practices, enabling improvements in care quality, greater professional autonomy, better coordination between healthcare services, and increased job satisfaction. These effects were evident in the reviewed literature, particularly in the areas of clinical effectiveness, risk management, education, continuous training, and personal and professional development.

CG aims to ensure the quality of healthcare services, prioritizing patient safety and reducing waste. It encompasses a comprehensive framework for care governance, ensuring that the design, coordination, and integration of different structures and processes adhere to excellence, following the best available evidence and clear accountability standards.

The adoption of CG models in healthcare and nursing services highlights the need for future research on this subject, particularly exploring the main CG models and their impact on the quality and safety of patient care. This would allow for an in-depth analysis and evaluation of their relevance and applicability across different contexts.

It is important to note that the reviewed articles did not specifically address clinical auditing and clinical information management. However, we emphasize the relevance of including these aspects in hospital CG as valuable contributors to the key dimensions discussed throughout the article.

The limitations of this review may be related to the diversity of perspectives on the topic, influenced by the specificities of professional nursing organizations and the structure of healthcare systems in the countries where the studies were conducted. Other constraints include researchers' limited experience and the timeframe restrictions of the review.

Authors' contribution

Conceptualization, M.T.F., S.R., T.S., F.O. and R.G.; data curation, M.T.F., F.O. and R.G.; formal analysis, M.T.F.; investigation, S.R. and T.S.; methodology, M.T.F., S.R., T.S., F.O. and N.A.; supervision, N.A.; validation, M.T.F., T.S. and N.A.; writing-original draft, M.T.F., T.S. and R.G.; writing-review and editing, M.T.F., S.R., T.S., F.O. and N.A.

Conflict of interest

The authors declare no conflicts of interest.