Transforming work place relationships through shared decision making.

Objective: Using Donabedian's Structure-Process-Outcomes (SPO) paradigm, this study explored the SPO linkages related to nurse-nurse leader shared decision making around workload issues, such as safe staffing assignments.

Background: Shared decision making represents nurses' control over practice, which is associated with positive nurse outcomes, such as job satisfaction. This study is based upon four project sites where nurse-led project teams addressed workload issues.

Methods: Participatory action research was used, with the authors acting as participant observers. Four sites were case ordered and analysed: least successful to most successful outcomes. Cross-case matrices were constructed to identify SPO linkages. Data included observation field notes, interviews and focus groups.

Results: Operations leaders with formal access to empowerment structures, such as information and resources, were the critical link to successful outcomes. Sites with conflict that blocked team-operations leader relationships were unable to engage in effective, sustainable decision making.

Conclusions: Effective work relationships among teams consisting of staff and front-line leaders contributed to successful outcomes, but team-operations leader relationships made the biggest difference. Conclusions: Formal access to power through leadership is critical for building and sustaining processes that promote and sustain nurses' control over practice.