the nurse practitioner clinical ladder program: a journey
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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
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
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“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
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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
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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
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NPCL Conceptual Framework
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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NPCL Activity
Common reasons for non-promotion:
-- incomplete application
-- exemplars of practice not supportive of level competencies
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Application
LevelApplications Submitted
Promotions
Achieved
2 16 7
3 8 6
Application Period: Q1-2014 to Q1-2017
NP Satisfaction – CL Impact
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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.
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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.
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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
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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
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