Recognizing the clinical nurse: The Meridian Health Clinical Advancement and Recognition of Excellence program
Article Outline
- Abstract
- 1. Introduction
- 2. Meridian Health's challenge
- 3. The Meridian Nursing Practice Model
- 4. Clinical Advancement and Recognition of Excellence (CARE) program
- 5. CARE program participation and outcomes
- 6. Conclusion
- Acknowledgments
- References
- Copyright
Abstract
This article describes the Meridian Health Clinical Advancement and Recognition of Excellence (CARE) program, an outcomes based clinical recognition program. The development of a new nursing care model led to the redesign of the health system's existing clinical ladder to further engage and reward clinical nurses for their expertise and contributions to improved patient outcomes. Development of the CARE program is discussed, as well as nursing participation and outcomes.
Keywords: Clinical Recognition program, Career ladder, Nursing model of care
1. Introduction
Clinical recognition programs or clinical ladders came into being in the 1980s in response to cyclical nursing staff shortages (Balasco & Black, 1988). With increasing challenges posed by a highly complex health care environment, clinical recognition programs must evolve to recognize the changing needs of the profession. If properly designed, these programs constitute not only an effective retention strategy but also a meaningful opportunity for acknowledging clinical nurses for their contributions in improving patient outcomes (Shapiro, 1998). This article will highlight one hospital system's efforts to enhance the practice environment by promoting a milieu that rewards the bedside nursing staff for their clinical expertise and recognizes their contribution to improved patient outcomes and the advancement of clinical scholarship.
2. Meridian Health's challenge
In response to the threat of a catastrophic and long-lasting nursing staff shortage, the nursing leadership at Meridian Health embarked on a journey to improve the practice environment for nurses across the hospital system. As part of a long-term strategy, a new, clearly articulated nursing model of care would need to be developed to guide nursing practice at Meridian Health. During a retreat for the Meridian nursing leadership, the existing Nursing Philosophy provided the basis for the identification of key concepts that supported nursing practice at Meridian. These concepts were then explicated in a practice philosophy that reflected the beliefs and values underpinning patient care at Meridian and that led the way to the new Meridian Nursing Practice Model. Staff input was included in every facet of the development of the Meridian Nursing Practice Model to assure that it accurately represented their practice.
3. The Meridian Nursing Practice Model
The Meridian Nursing Practice Model is patient centered. It acknowledges and respects the patient as an informed, discriminating consumer. Care provided by all nurses at Meridian is competent, effective, and collaborative, valuing the patient's beliefs, preferences, and needs. In the new practice model, patient acuity and needs drive the budget, hours of patient care per patient day, staffing, and skill mix. A graphic representation of the key concepts provides a visual interpretation of the model (see Fig. 1).
Fig. 1.
Meridian Health Nursing Practice Model.
Structural dimensions that support nursing practice at the point of patient care delivery facilitate and foster the care model. They include clinical expertise, research, education, and shared governance. These dimensions acknowledge the need for evidence-based care, the satisfaction that results from professional autonomy and differentiated practice, the importance of professional growth and development, and the necessity of coordinated services that support a continuum of care. Together, the elements of care and the structural dimensions of care connect nursing practice to patient outcomes to improve care and help contain costs.
Infusion of the new model into practice occurred in two major ways. The model was used to create “model of care” nursing units at each of the three Meridian hospitals to serve as “laboratories of innovation,” and the existing clinical ladder was redesigned. Increased staffing, a no-float policy, enhanced bedside technology, and a dedicated clinical specialist/educator, were part of the design for the model of care units. Nursing and patient quality indicators are used to evaluate the efficacy of these components to improve the nursing practice environment. What is learned on these units is then transported to additional units each year until the new nursing model is fully functional on all Meridian nursing units.
4. Clinical Advancement and Recognition of Excellence (CARE) program
The Meridian Nursing Model guided the redesign of the system clinical ladder program. The purpose of the ladder redesign was to truly reflect differing levels of clinical expertise. The redesigned program is based on outcomes and, therefore, translates into a more meaningful program for the nursing staff. Development of the new clinical recognition program followed the process of the new practice model: Nursing leaders facilitated the process redesign while the staff fully participated in creating the new, updated program.
In 2002, the CARE program was born. Staff members, including union leadership, were included in every aspect of the design and development of the CARE program. Initially, many were concerned about changing the clinical ladder system that had been in effect for years. Staff on the steering committee took full responsibility for diffusing this new and innovative recognition program. To get all staff members on board, the CARE steering committee scheduled and staffed around-the-clock education sessions, as well as individual one-on-one sessions. In addition, steering committee members completed their own applications, which were used as exemplars for other staff members to follow. In 2003, participation in the CARE program was required to continue to work on a model of care unit.
In contrast to the clinical ladder that had been in place since the early 1980s, the Meridian Health CARE program engages staff nurses in a process of reflection to help them identify competencies and expertise they have achieved at four different advancement levels. The four advancement levels in the CARE program are as follows: Clinical Nurse I, Clinical Fellow (Level II), Clinical Resource (Level III), and Clinical Scholar (Level IV). Descriptions for each level are presented in Table 1. The committee designed recognition pins for each level of achievement, and except for the first level, nurses are financially compensated for each level achieved.
Table 1. Descriptions of Meridian Health CARE levels
| Clinical Nurse I | The nurse who progresses to the Clinical Nurse I level has completed orientation and all basic competencies to perform safely and acceptably on a particular patient care unit. The Clinical Nurse I demonstrates understanding of basic scientific principles of nursing practice and adheres to standards of practice for nursing. |
| Having experienced a number of real patient care situations, the Clinical Nurse I is adept at using guidelines in caring for patients and families. He or she safely implements interventions and procedures and has developed basic technical skills necessary to function well in the practice setting. The Clinical Nurse I begins to perceive recurrent meaningful patterns in clinical practice. He or she works to organize and prioritize care within own patient care assignment with assistance, recognizes emergency situations, and initiates appropriate actions. | |
| Clinical Fellow: Level II | The Clinical Fellow has started to accumulate experiences in caring for patients and families and begins to recognize patterns that influence future practice. The Clinical Fellow begins to be consciously aware of how his or her actions may affect goals and the overall plan of care and develops relationships with patients and family members that positively affect patient experience. |
| The Clinical Fellow can individualize care based upon knowledge of patient and family needs, has knowledge of specific conditions, and uses the teaching/learning process with individuals and families. He or she begins to gain experience in working with particular patient populations, possesses a basic competence in their care, and is adaptable in managing clinical situations. At this level, the nurse demonstrates a mastery of unit-specific technical skills and understands the challenges inherent in prioritizing and organizing the patient care environment. | |
| Clinical Resource: Level III | The Clinical Resource displays an in-depth understanding of the clinical picture as a whole rather than its specific aspects. The Clinical Resource has learned from past experiences what to expect in particular situations and modifies actions and goals in response to these events. |
| The Clinical Resource has gained experience in working with particular patient populations and is proficient in their care. An experience-based aptitude to recognize the whole situation allows the Clinical Resource to anticipate the likely course of events and to appreciate when the expected normal situation does not materialize. He or she can often detect clinical deterioration or patient problems and tailors care and interventions to ensure the best patient outcomes. The Clinical Resource is recognized by peers as a resource in the care of specific patient populations in his or her area of specialization and uses acquired in-depth knowledge about the care of a particular patient population to affect patient outcomes. He or she provides specific and explicit guidance to clinicians and Clinical Fellows in patient care situations and positively influences the clinical practice of other nurses and colleagues. | |
| Clinical Scholar: Level IV | The nurse who progresses to the Clinical Scholar level displays an in-depth knowledge of the entire clinical practice environment and functions at the highest level in the areas of clinical practice, education, research, and self-governance. |
| The practice of a Clinical Scholar is distinguished by a comprehensive understanding of the impact of illness on the lives of patients and family members. In meeting patient/family needs, the Clinical Scholar demonstrates keen foresight in anticipating problems and concerns, is alert to the unexpected, and takes steps to mitigate untoward outcomes. To achieve the best possible patient outcomes, the clinical scholar engages in expert critical thinking, resulting in clinically sound evaluation and practice. He or she vigorously empowers and advocates for patients and families, enabling their participation in decision making and goal setting. | |
| The Clinical Scholar is recognized by peers as an expert in his or her practice area or area of specialization, and he or she actively and positively exerts influence on the clinical practice of other nurses and colleagues. The environment and functioning of the clinical unit are clearly enhanced when a Clinical Scholar is working, as he or she can coordinate multiple activities and needs and often implements innovative approaches to patient and unit challenges. |
On the basis of the new Meridian Health nursing model of care, nurses must address criteria in clinical practice, education, shared governance, and research areas demonstrating increasing levels of expertise as they advance through the four levels. Each nurse presents a portfolio documenting the outcomes in each of these areas. Examples of behaviors that reflect each criterion provide guidance, and evaluation is supported by a variety of tools such as case study forms, questionnaires, and portfolio guidelines.
For clinical practice, the nurse may submit either a clinical exemplar or a case study documenting a patient care situation that demonstrates the nurse's clinical judgment and the attributes of the appropriate CARE advancement level. Peer evaluators assess whether the nurse demonstrates the qualities of the particular CARE level including the nurse's use of appropriate resources to support effective care delivery, the nurse's recognition and documentation of his or her contribution to patient/family or system outcomes, and how the experience has helped the individual improve practice.
For the education criteria, the nurse provides evidence in three areas: self-education to enhance the individual's own knowledge and skills; peer education to enhance the knowledge and skills of colleagues, members of the health care team, or both; and patient/family/community health education to provide important health information to consumers. To demonstrate involvement in shared governance, the nurse accepts responsibility to participate in decision making on unit, hospital, and system-wide levels and to contribute actively to interdisciplinary cooperation and collaboration. To meet this criterion, the nurse not only must document attendance at meetings but also must indicate specific contributions made to the practice environment, such as the nurse's actual role in new policy development and actual improvements in patient care through interdisciplinary, collaborative practice.
Research is central to the Meridian Nursing Model and, therefore, is a critical criterion at all levels in the CARE program. In the original clinical ladder, to achieve the highest level, the individual nurse was required to complete a research project or submit a publishable paper. Because of this requirement, very few nurses achieved Level IV status. With the new CARE program, it was determined that it would not be realistic for each nurse to complete an individual project. Instead, collaboration as part of a team in either an outcome-based performance improvement project, evidence-based practice project or research project is strongly recommended. Dedicated nurse researchers are available to support the staff members in their endeavors. In this way, research expertise is developed over the course of a career, with more experienced practitioners mentoring the less experienced.
5. CARE program participation and outcomes
The Meridian Health nursing leadership's goal is to have 100% participation in the CARE program. Table 2, Table 3 demonstrate movement toward this goal. At the present time, close to 56% of eligible nurses across the health system has advanced on the CARE program; on the model of care units, 82% of eligible RNs are participating.
Table 2. CARE program participation per Meridian Hospital (as of 12/14/05)
| Total full-time/part-time RNs | Eligible RNs (>1.4 years) | RNs on CARE | Percentage of RNs on CARE | |
|---|---|---|---|---|
| JSUMC | 641 | 486 | 292 | 60 |
| OMC | 408 | 281 | 155 | 55.16 |
| RMC | 321 | 300 | 149 | 49.6 |
| System | 1,370 | 1,067 | 596 | 55.85 |
Table 3. CARE program participation by level (as of 12/14/05)
| JSUMC | OMC | RMC | Total | |
|---|---|---|---|---|
| Fellow | 106 | 47 | 37 | 190 |
| Resource | 83 | 58 | 51 | 192 |
| Scholar | 103 | 50 | 61 | 214 |
| Total | 292 | 155 | 149 | 596 |
Further evaluation of the outcomes of the CARE program indicates that RNs in the program have a 42.7% greater length of service than nurses not engaged in the program. Average patient satisfaction percentile ranks across the system are higher on units with 50% or more of the RN staff on the CARE program (see Table 4). Additionally, units with 50% or greater CARE program participation met the maximum target score of 85% for patient satisfaction (see Table 5). Additional quality measures that are also being collected and aggregated include patient fall rates. Over the past year, units with 50% or greater RN staff on the CARE program had a lower patient fall index (see Table 6).
Table 4. Patient satisfaction percentile rank for units with 50% or higher participation in the CARE program
Table 5. Percentage of units with 50% or greater CARE program participation meeting the maximum target score of 85% for patient satisfaction
Table 6. Comparison of fall rates and participation in the CARE program (patient falls per 1,000 patient days)
Some of the most important outcomes of the CARE program are the individual portfolios that are generated by each nurse participating in the program. The peer reviewers continue to be impressed at the wonderful work that is being accomplished on each nursing unit. Teams of nurses on individual units are collaborating on performance-improvement activities and evidence-based practice and research projects. They are scrutinizing policies and procedures to assure that best practice is being followed. Most important, nurses are reflecting on their work and taking ownership for their practice and outcomes. Change never comes easily; however, the nurses at Meridian Health have embraced the CARE program, and the more experienced nurses are guiding the novice nurses in completing their applications.
6. Conclusion
Hospitals need to be more proactive in dealing with current and future nursing staff shortages by both developing successful recruitment initiatives and paying substantial attention to retain highly qualified and highly skilled nurses. Keeping nurses engaged at the bedside continues to be an ongoing challenge. The Meridian Health CARE program constitutes a realistic, sustainable program that addresses nursing staff shortage by recognizing and rewarding clinical nurses and by acknowledging their contribution to improved patient outcomes and the advancement of clinical scholarship.
Acknowledgments
Special thanks to Wendy Mancini, MSN, RN, CARE Program Manager for Meridian Health, for analyzing program outcomes.
References
PII: S1557-3087(06)00004-7
doi:10.1016/j.teln.2006.02.003
© 2006 National Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
