The Nurse Practitioner Clinical Ladder Program:

A Journey to Professional Nursing Excellence

Lisa Paplanus, DNP, ACNP-BC, ANP-BC, CCRN, RN-C

Patricia Bartley-Daniele, PhD, FNP-BC, CCRN, CNRN, CPAN, CAPA

Patricia Chibbaro, CPNP, MSN

Sigma Theta Tau - 28th International Nursing Research Congress

Dublin, Ireland

July 27, 20171

Conflicts of Interest / Disclosures

NONE

2

Learning Objectives

1. Describe the rationale for the Nurse Practitioner Clinical Ladder (NPCL) program development.

2. Discuss the NPCL program structure and process standards

3. Analyze the impact of the NPCL program on NP satisfaction, recruitment, retention, and rewards.

4. Postulate NPCL program implications for current and future advanced practice nursing roles.

3

Background

Uniqueness of NP role: How to measure satisfaction?

Successful staff nurse clinical ladder/residency program at NYULMC

No program for advancement/retention of NPs at NYULMC

Strong support from Chief Nursing Officer and Senior Director for Advanced Practice Nurses (APN)

4

NPCL Committee Goals

Develop an evidence-based NPCL advancement program that promotes recognition, reward, and NP retention

Collect baseline data

Emphasize transparency and inclusiveness

Evaluate program effectiveness

Publish and present the NPCL experience to inform Advanced Nursing Practice

5

“The Journey begins...”

Review the literature

Measure NP job satisfaction

Adapted Misener NP Job Satisfaction Scale

Pre/post implementation of the NPCL program

Develop NPCL Structure and Process Standards based on the NYULMC Staff Nurse Clinical Ladder and informed by

Nursing’s Marker Model

Benner’s Novice to Expert Model

Donabedian’s Model of Quality Health Care

American Nurses Credentialing Center’s Forces of Magnetism Model

NP Core Competencies

6

Misener NP Job Satisfaction Survey

Likert scale 1 to 6: NPs average satisfaction scores >4

Open-ended questions were added to the survey

All NP respondents indicated need for ongoing mentorship and support

Newly-hired NP respondents rated NP Orientation Program

favorably but were dissatisfied with ability to function

independently after orientation

7

NPCL Structure Standard

Promote clinical excellence and professional growth

Recognize and reward APN nursing staff by establishing levels of advanced nursing practice

Provide system for incentives, recognition, and compensation to support achievement and levels of advanced NP practice

Define a structure for NPCL integration into employee annual performance appraisal

8

NPCL Conceptual Framework

9

Benner, P. E. (2000). From novice to expert: Excellence and power in clinical nursing practice. United States: Addison-Wesley Publishing.

Practice Levels 1A and 1 B

NP Level 1A• Newly hired with less than 2 years of clinical NP practice

• Expects to gain national NP certification within 1 year

• Engages in Orientation Programs and NP Mentoring Program

NP Level 1B• Newly hired with at least 2 years of clinical NP practice

10

NP Level 2

• NPs with a at least 5 years of clinical NP practice

• Exceeds competency performance criteria at NP Level 1B

• Applies for and achieves competency performance criteria & behaviors for NP Level 2

Practice Level 2

11

NP Level 3

• NPs with a minimum of 8 years of clinical NP practice

• Exceeds competency performance criteria & behaviors at NP Level 2

• Possesses doctoral degree, or is enrolled in a doctoral program, OR has an equivalent level of combined NP experience and performance

Practice Level 3

12

NP Performance Differentiation

Practice levels emphasizing common threads of respect, teamwork and leadership

Competency Domains

Clinical Practice & Outcomes

Academics & Advanced Nursing Expertise

Leadership & Administrative Support

Community Service

Professionalism

13

Built upon from NPCL Level 1A to Level 3

Each competency is assigned an arbitrary value of 1

Competency scores are totaled across 4 Domains exclusive of the Professionalism domain

Benchmark set at 80% for promotion to next level

Benchmark set at 100% in the Professionalismdomain for promotion to ANY Level

Competencies within Domains

14

NP Level 1A NP Level 1B NP Level 2 NP Level 3

Complies with protocols, clinical pathways and documentation guidelines.

Incorporates evidence-based research findings into clinical practice.

Tailors care /coordinates an evidence-based plan of care for patient and family.

Develops evidence-based patient care initiatives / programs.

Contributes to plan of care through participating in daily transdisciplinary patient care rounds.

Integrates transdisciplinaryrecommendations into the plan of care.

Incorporates patients’ varyinglevels of acuity into the daily service needs and priorities.

Develops a patient / family transitional plan of care based on the evidence.

Competencies

Exemplar: Clinical Practice & Outcomes

15

NPCL Process Standard

Describe the process for NP application for promotion on the Clinical Ladder

Identify the required application documents

Recognize the NPCL Review Committee as the evaluative body

Incorporate opportunity for discussion with APN leadership on promotional decisions

16

NPCL Review Committee

Forum for review of NP promotion requests

7 rotating members selected from the NPCL Committee

NPCL Review Committee Coordinator and Co-coordinator

elected by NPCL Committee

facilitate application review processes and activities

report Review Committee’s recommendations to the NPCL Committee and APN leadership

Committee meets quarterly to review applications

17

NPCL Application & Promotion Process

NPCL REVIEW COMMITTEE

Letter of Request for Promotion

Curriculum Vitae

Competency Checklist w/ exemplars

1 NP Peer Letter of Support

1 HCP Letter of Support

Completed Checklist

Senior Director APN

18

NPCL Outgrowths

Formal NP Mentoring Program

Improved NP Onboarding & Orientation Program

Re-evaluation of the current NP roles

Formal program evaluation

Publication of the experience in peer-reviewed journal

NP Level competencies incorporated into organizational performance evaluation and reward system

19

NPCL Outcome Measurement

Ladder promotions

Job satisfaction

Recruitment

Retention

20

NPCL Activity

Common reasons for non-promotion:

-- incomplete application

-- exemplars of practice not supportive of level competencies

21

Application

LevelApplications Submitted

Promotions

Achieved

2 16 7

3 8 6

Application Period: Q1-2014 to Q1-2017

NP Satisfaction – CL Impact

22

2011 2013 2016

Time off to serve on professional committees 3.34 3.52 3.78 13.0%

Reward distribution 3.38 3.60 4.17 23.6%

Input into organizational policy 3.65 3.74 3.91 7.0%

Opportunity for professional growth 4.01 4.09 4.29 7.0%

Opportunity to develop and implement ideas 4.09 4.14 4.32 5.8%

Sense of value for what you do 4.32 4.22 4.46 3.3%

Level of autonomy 4.67 4.51 4.83 3.4%

Avg Score / Survey Year% ↑

2011-2016Misener NP Survey Question

NPCL Impact on Retention of New NP Hires

The NPCL, APN orientation program and NP mentorship program have contributed to retention of new NP hires.

23

For 2016 hires, data about terminations only available through May 2017.

Hire YearTotal Hired

Main Campus

Terminated

in <= 2yrRetained % Retention

2013 39 11 28 72%

2014 95 24 71 75%

2015 145 17 128 88%

2016

Jan-May39 3 in<=1 yr 36 92%

NPCL Implications for Current and Future NP Roles

Organizational commitment to an NPCL is critical for NP job satisfaction, recruitment, and retention.

Formalized NP Orientation and Mentorship programs are foundational in meeting the professional needs of NPs.

Formal incorporation of NPCL competencies into NP annual performance appraisal and reward systems supports continued NP role development.

NPCL review committee provides a forum for advanced leadership opportunities.

24

NPCL next steps…

Expand NPCL model to other APN roles (CNS, CRNA)

Evaluate impact of Mentorship Program on NPCL promotional success

Link NPCL level to NP-sensitive patient quality and safety metrics

Publish findings in peer-reviewed journal and disseminate findings at professional meetings

25

Kimberly S. Glassman, PhD, RN, NEA-BC, Senior Vice President and Chief Nursing Officer,

for recognizing the primacy of NPs in the current health care environment

Maria T. Brillant, MS,MA, RN, ANP, NEA-BC, Senior Director, Advanced Practice Nurses,

and

Carolyn Wray-Williams , MS, RN, ANP, NE-BC, Director of Advanced Practice Nurses,

for their unfailing support in this groundbreaking endeavor

Special thanks

26

References

Adeniran, R. K., Bhattacharya, A., & Adeniran, A. A. (2012). Professional excellence and career advancement in nursing. Nursing Administration Quarterly, 36, 41-51. doi:10.1097/naq.0b013e31823b0fec.

Altier, M. E. & Krsek, C. A. (2006). Effects of a 1-year residency program on job satisfaction and retention of new graduate nurses. Journal for Nurses in Staff Development, (22)2: 70-77.

American Nurses Credentialing Center. (2016). Magnet Recognition Program. Retrieved December 1, 2016, from American Nurses Credentialing

Center, http://www.nursecredentialing.org/magnet

Antoniazzi, C. D. (2011). Respect as experienced by registered nurses. Western Journal of Nursing Research, 33, 745-766.

Benner, P. E. (2000). From novice to expert: Excellence and power in clinical nursing practice. United States: Addison-Wesley Publishing.

Cronenwett, L. R. (2012). Molding the future of advanced practice nursing. Nursing Outlook, 60(5), 241-248. doi:10.1016/j.outlook.2012.06.010

De Milt, D. G., Fitzpatrick, J. J. & Mc Nulty, R. (2011). Nurse practitioners’ job satisfaction and intent to leave current positions, the nursing profession, and the nurse practitioner role as a direct care provider. Journal of the American Academy of Nurse Practitioners, (23): 42-50.

Donabedian, A. (1998). The quality of care. JAMA, 260, 1743. doi:10.1001/jama.1988.03410120089033.

Elliott, N. (2016). Building leadership capacity in advanced nurse practitioners – the role of organizational management. Journal of NursingManagement. doi:10.1111/jonm.12444.

Elliott, N., Begley, C., Sheaf, G., & Higgins, A. (2016). Barriers and enablers to advanced practitioners’ ability to enact their leadership role: A scoping review. International Journal of Nursing Studies, 6024-45, doi:10.1016/j.ijnurstu.2016.03.001.

Goode, C. J. & Williams, C. A. (2004). Post-Baccalaureate nurse residency program. JONA, (34)2: 71-77.

Goode, C. J., Lynn, M. R., Krsek, C., & Bednash, G. D. (2009). Nurse residency programs: an essential requirement for nursing. Nursing Economics, (27)3: 142-159.

Goodloe, L. R., Sampson, R. C., Munjas, B. W., Whitworth, T., Lantz, C. D. et al. (1996). Clinical ladder to professional advancement program: An evolutionary process. JONA, 26(6): 58-64.

Haag-Heitman, B., & George, V. (2011). Peer review in nursing: Principles for successful practice. Sudbury Ma: Jones and Bartlett Publishers.

Harrington, S. (2011). Mentoring new nurse practitioners to accelerate their development as primary care providers: A literature review. Journal of the American Academy of Nurse Practitioners, 23: 168-174.

Hespenheide, M., Cottingham, T.,& Mueller, G. (2011). Portfolio use as a tool to demonstrate professional development in advanced practice nursing practice. Clinical Nurse Specialist, 25, 312-320. doi:10.1097/nur.0b013e318233ea90,

27

Krugman, M., Bretshneider, J., Horn, P. B., Krsek, C. A., Moutafis, R. A. & Smith, M. O. (2006). The national post-baccalaureate graduate nurse residency program: a model for excellence in transition to practice. Journal for Nurses in Staff Development, (22)4: 196-205.

Lutes, J. (1998). A clinical ladder for NNPs. Neonatal Network, 17(8): 47-48.

Misener, T. R. & Cox, D. L. (2001). Development of the Misener nurse practitioner job satisfaction scale. Journal of Nursing Measurement, 9(1): 91-108.

National Organization of Nurse Practitioner Faculties. (2016). Nurse practitioner core competencies. Retrieved January 12, 2016, from National

Organization of Nurse Practitioner Faculties, http://cymcdn.com/sites/ww.nonpf.olrg/resource/resmgr/compenties/npcorecompetenciesfinal2012.pdf

NYU Hospitals Center (2006). Clinical Ladder Program Manual.

Paplanus, L. M., Bartley-Daniele, P., & Mitra, K. S. (2014). Knowledge translation: A nurse practitioner clinical ladder advancement program in a

university-affiliated medical center. Journal of the American Association of Nurse Practitioners, 26, 424-437. doi:10.1002/2327-6924.12082.

Porter-O’GradyTim. (2011). Leadership at all levels. Nursing Management (Springhouse), 42, 32-37. doi:10.1097/01.numa.0000396347.49552.86.

Professional Excellence Program – Advanced Practice Nurses. (December 2010). Holy Name Medical Center, Teaneck NJ, Unpublished program description.

Robert, H.M., et al. (2011). Robert's Rules of Order Newly Revised. Sarasota, Florida:Da Capo Press.

Rosenfeld, P., Smith, M. O., Iervolino, L. & Bowar-Ferres, S. (2004). Nurse residency program. A 5-year evaluation from the participants’ perspective. JONA, (34)4: 188-194.

Rowell, R., Forsythe, P., Avallone, D. & Kloos, J. (2008). Moving on up! Implementing an effective APN promotional program. The Nurse Practitioner, 33(12): 39-44.

Walker, B., & Hamilton, R. T. (2010). Employee-Employer grievances: A review. International Journal of Management Reviews, 13, 40-58.

Warman, G. A., Williams, F., Herrero, A., Fazeli, P., & White-Williams, C. (2016). The design and redesign of a clinical ladder program. Journal for

Williams, C. A., Goode, C. J. & Krsek, C. (2007). Postbaccalaureate nurse residency. 1-year outcomes. JONA, (37)7/8: 357-365. Nurses in Professional Development, 32, E1-E7. doi:10.1097/nnd.0000000000000307

References (cont.)

28