EVIDENCE- Clinical Ladder: Strategy in Professional ...

[Pages:3]EVIDENCEBASED CARE SHEET

Authors

Nathalie Smith, RN, MSN, CNP Cinahl Information Systems, Glendale, CA

Arsi L. Karakashian, RN, BSN Armenian American Medical Society of

California

Reviewers

Dawn Stone, PhD(c), RN, ANP, COHN-S Darlene Strayer, RN, MBA

Cinahl Information Systems, Glendale, CA Nursing Executive Practice Council Glendale Adventist Medical Center, Glendale, CA

Editor

Diane Pravikoff, RN, PhD, FAAN Cinahl Information Systems, Glendale, CA

Clinical Ladder: Strategy in Professional Development

What We Know

> The clinical ladder is a type of employee incentive program that outlines the skills needed to rise to higher ranks within the organization while continuing to provide patient care. Clinical ladders are designed to promote professional development, improve patient care, enhance job satisfaction, and prevent nursing turnover. (For information regarding employee incentive programs, see Evidence-Based Care Sheet: Employee Incentive Programs )(2,6,13,16) ? The traditional path of career advancement for registered nurses (RNs) is from the bedside to a role in administration and/or education; career advancement of RNs can contribute to a shortage of highly skilled and experienced RNs in direct patient care. Clinical ladder programs use financial incentives and professional recognition as tools to encourage nurses to continue providing direct patient care while advancing their careers(2,6,13,18) ? Even when progressively increasing salaries are provided, retaining qualified RNs who provide direct patient care eliminates the costs of nursing turnover related to advertising, recruiting, orientation, and training, and reduces problems related to nursing turnover, including patient care errors and loss of organizational knowledge(4)

> Healthcare organizations in the United States began developing RN clinical ladder programs during the nursing shortage in the 1970s(6,10,12,15,16) ? In a 1972 article published in the Journal of Nursing Administration, Zimmer asserted that programs in healthcare organizations that offer recognition and financial incentives influence RNs to remain in direct patient care in order to focus their expertise on clinical practice(19) ? Benner's widely referenced 1982 work, From Novice to Expert, provides a framework for many current clinical ladder programs(2,6,10,12,16) ?Benner adapted the Dreyfus Model of Skill Acquisition to nursing and proposed that nurses advance through five levels of proficiency with education and experience: novice, advanced beginner, competent nurse, proficient nurse, and expert nurse(1) - According to Benner, "The Dreyfus Model of Skill Acquisition, applied to nursing and combined with an interpretive approach to describing nursing practices... indicates the importance of career ladders within clinical nursing practice and adds to our understanding of the need for and acceptance of the emergence of clinicians and clinical specialists in the patient-care setting"

> Clinical ladder programs are emerging in other countries(5,9) ? The Japanese Society of Intensive Care Medicine, Division of Nursing, implemented a clinical ladder program with the goal of teaching and maintaining clinical skills, management skills, proactive career development, and ethics(9) ? In the first year of implementation at the Department of Nursing of the Wonkwang University School of Medicine, South Korea, 7 nurses were promoted to managerial positions(5)

December 22, 2017

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright?2017, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

? A questionnaire of nurses in clinical ladder programs across Taiwan revealed that nurses who advanced to leadership roles were more likely to hold positive beliefs towards and practice evidence-basedcare(18)

> Common elements of all clinical ladder programs include(2,6,7,10,12,14,16,18)

? an application and acceptance process that is linked to the annual performance appraisal and requires self-appraisal, career portfolio review, peer review, and/or appraisal by the nurse manager(3,6,7,12,15) ?Acceptance to clinical ladder programs can also be based on education(3,15)

? the establishment of 3?4 clearly defined levels of nursing practice(2,7,10,12,16)

?Level 1 RNs are generally new RN graduates, or novices, who use their developing knowledge base in accordance with policies, procedures, and standards of care to guide their practice; these nurses are expected to seek appropriate guidance and support

?Level 2 RNs are competent clinicians who have mastered technical skills and gained experience to guide their practice, but are expected to require occasional assistance from other members of the healthcare team

?Level 3 RNs are experienced, confident clinicians who are considered proficient in their practice; these nurses are expected to be efficient and flexible in their practice, demonstrate excellent communication and collaboration skills, and demonstrate proficiency in managing planned and unplanned events

?Level 4 RNs are expert nurses who have a comprehensive knowledge base and are considered leaders, role models, and mentors to other members of the healthcare team

? the provision of salary increases and/or bonuses with each level of nursing practice(2,7,10,12,16)

? a basis of core principles, or domains, each with clearly defined competencies that are specific to the 3?4 practice levels. Common domains are(10,14)

?critical thinking ? education ?evidence-based practice ?clinical expertise ? advocacy ? leadership

- Examples of competencies in the leadership domain based on practice level in the clinical ladder program at Rush University Medical Center in Chicago are as follows:(10)

- Level 1 RN: supports unit goals and initiatives for change; demonstrates beginning delegation skills - Level 2 RN: demonstrates the ability to effectively precept staff and students; delegates effectively and consistently - Level 3 RN: serves as a role model and demonstrates proficient leadership skills - Level 4 RN: functions as a mentor and assumes a leadership role > Much of the available literature about clinical ladder programs provides a descriptive account of individual programs. Staff satisfaction surveys and personal interviews are performed to collect data regarding the effect of clinical ladder programs on nurse satisfaction and perception of professional development. Clinical ladder programs that are cited in the literature have been credited with(2,6,8,10,12) ? enhancing a sense of empowerment in nurses(8) ? promoting job satisfaction(10,17) ? promoting knowledge development and professional accomplishment(2,3,6,8,9,10,12,13) ? promoting team building and peer support(2,12) ? being a useful tool in succession planning(7,12)

> Clinical ladder programs should not be limited to RNs. These programs are important for advanced practice nurses (e.g., nurse practitioners, clinical nurse specialists, nurse anesthetists, nurse midwives) to promote job satisfaction, job retention, evolving role responsibilities, and professional development(11)

What We Can Do

> Become knowledgeable about the use of clinical ladder strategies as a tool for professional development and retention so you can accurately assess the benefits of introducing or improving a clinical ladder program in your healthcare organization; share this information with your colleagues(18)

> Collaborate with members of administration, human resources, finance, and other appropriate departments to evaluate the feasibility of introducing or improving a clinical ladder program in your organization ? After initiating or improving the clinical ladder program at your facility, participate in continued assessment of its success as measured by nurses' reported job satisfaction, perceptions of the recognition they receive for accomplishments, and turnover rates

> Collaborate with the human resources department regarding efforts for nurse recruitment, hiring, and orientation to promote the benefits of the clinical ladder program in your healthcare organization ? Verify that all eligible employees have current, written information about the program, its requirements, the application process, and the personal and professional benefits it offers

Coding Matrix

References are rated using the following codes, listed in order of strength:

M Published meta-analysis SR Published systematic or integrative literature review RCT Published research (randomized controlled trial)

R Published research (not randomized controlled trial) C Case histories, case studies G Published guidelines

RV Published review of the literature RU Published research utilization report QI Published quality improvement report

L Legislation PGR Published government report PFR Published funded report

PP Policies, procedures, protocols X Practice exemplars, stories, opinions GI General or background information/texts/reports U Unpublished research, reviews, poster presentations or other such materials

CP Conference proceedings, abstracts, presentation

References

1. Benner, P. (1982). From novice to expert. American Journal of Nursing, 82(3), 402-407. (X)

2. Burket, T. L., Felmlee, M., Greider, P. J., Hippensteel, D. M., Rohrer, E. A., & Shay, M. L. (2010). Clinical ladder program evolution: Journey from novice to expert to enhancing outcomes. Journal of Continuing Education in Nursing, 41(8), 369-374. doi:10.3928/00220124-20100503-07 (X)

3. Clinical ladder program. (n.d.). St. Joseph's Health. Retrieved December 12, 2017, from (GI)

4. Jones, C. B., & Gates, M. (2007). The costs and benefits of nurse turnover: A business case for nurse retention. The Online Journal of Issues in Nursing, 12, 3. Retrieved December 12, 2017, from NurseRetention.aspx (RV)

5. Ko, Y. K., & Yu, S. (2014). Clinical ladder program implementation: A project guide. The Journal of Nursing Administratio, 44(11), 612-616. doi:10.1097/ NNA.0000000000000134 (R)

6. Korman, C., & Eliades, A. B. (2010). Evaluation through research of a three-track career ladder program for registered nurses. Journal for Nurses in Staff Development, 26(6), 260-266. doi:10.1097/NND.0b013e31819b5c25 (R)

7. Mathias, J. M. (2008). Clinical ladder benefits staff, manager. OR Manager, 24(7), 13-14. (X)

8. Min, A., & Kim, I. S. (2013). Relationship of perception of clinical ladder system with professional self-concept and empowerment based on nurses' clinical career stage. Journal of Korean Academy of Nursing Administration, 19(2), 254-264. doi:10.11111/jkana.2013.19.2.254 (R)

9. Moro, E., Nishina, N., Utsunomiya, A., Saito, M., Imura, K., Odera, T., & Kuwahara, Y. (2015). Development and application of the clinical ladder program for the intensive care nurses in Japan. CONNECT: The World of Critical Care Nursing, 9(4), 153-154. (CP)

10. Murphy, M., Hinch, B., Llewellyn, J., Dillon, P. J., & Carlson, E. (2011). Promoting professional nursing practice: Linking a professional practice model to performance expectations. Nursing Clinics of North America, 46(1), 67-79. doi:10.1016/ur.2010.10.009 (X)

11. Paplanus, L. M., Bartley-Daniele, P., & Mitra, K. S. (2014). Knowledge translation: A nurse practitioner clinical ladder advancement program in a university-affiliated, integrated medical center. Journal of the American Association of Nurse Practitioners, 26(8), 424-437. doi:10.1002/2327-6924.12082 (RV)

12. Pierson, M. A., Liggett, C., & Moore, K. S. (2010). Twenty years of experience with a clinical ladder: A tool for professional growth, evidence-based practice, recruitment, and retention. Journal of Continuing Education in Nursing, 41(1), 33-40. doi:10.3928/00220124-20091222-06 (X)

13. Ries, E. (2016). Ladders that matter in clinical care. PT in Motion, 8(3), 16-24. (X)

14. Riley, J. K., Rolband, D. H., James, D., & Norton, H. J. (2009). Clinical ladder: Nurses' perceptions and satisfiers. Journal of Nursing Administration, 39(4), 182-188. doi:10.1097/NNA.0b013e31819c9cc0 (R)

15. Sauer, D., Miller, J., Falatko, N., Wann, K., & Kohler, S. (2016, September 1). Implementing a respiratory care department 'clinical ladder'. Retrieved December 12, 2017, from 2016/09/implementing-respiratory-care-department-clinical-ladder/ (GI)

16. Watts, M. D. (2010). Certification and clinical ladder as the impetus for professional development. Critical Care Nursing Quarterly, 33(1), 52-59. doi:10.1097/ CNQ.0b013e3181c8e333 (RV)

17. Weng, Y. H., Chen, C., Kuo, K. N., Yang, C. Y., Lo, H., Chen, K. H., & Chiu, Y. W. (2015). Implementation of evidence-based practice in relation to a clinical nursing ladder system: A national survey in Taiwan. Worldviews on Evidence-Based Nursing, 12(1), 22-30. doi:10.1111/wvn.12076 (X)

18. Zehler, J., Covert, C., Seiler, L., Lewis, M., Perazzo, J., & Beery, T. A. (2015). One rung at a time: What affects clinical ladder participation? Nursing Management, 46(4), 30-37. doi:10. 1097/01.NUMA.0000462369.75906.04 (X)

19. Zimmer, M. J. (1972). Rationale for a ladder for clinical advancement in nursing practice. Journal of Nursing Administration, 2(6), 18-24. (X)

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