Professional practice programs are essential for strengthening nursing professionalism and enhancing job satisfaction. Increasingly, structures to support nurse empowerment in controlling their practice and experiencing a positive work environment are linked to high-quality patient outcomes and achievement of ANCC Magnet Recognition®.
The University of Colorado Hospital (UCH), a three-time Magnet®-designated hospital, developed a practice program called UEXCEL in the late 1980s, which has been in continuous operation for more than 22 years. It has proven to be a significant force in developing professional nurse leadership, autonomy, and empowerment and in improving patient outcomes. UEXCEL stands for the University of Colorado Hospital’s Excellence in Clinical Practice, Education, Evidence-based Practice, and Leadership. This nurse-led program promotes a highly educated nursing workforce (84.5% of our nurses have bachelor of science in nursing degrees); 44% are certified in their specialty. Half of our 1,500 clinical nurses are graduates of our national UHC/American Association of Critical-Care Nurses Post-Baccalaureate Nurse Residency Program. UEXCEL also drives succession planning; 53% of current nurse leaders at UCH are former UEXCEL participants who’ve advanced to higher practice levels.
The foundation for UEXCEL was adapted from Patricia Benner’s novice-to-expert framework for the stages of clinical competence and is based on principles of the Magnet Recognition Program. (See UEXCEL governance by clicking the PDF icon above.)
Practice program structure
Regardless of service, specialty, or practice location, every clinical nurse who practices at the point of care across our hospital is a UEXCEL member. This program isn’t based on a point system; nor does it include advanced practice nurses or those holding specialty roles (such as case manager). Every clinical registered nurse (RN) has a job description, job code, and classification as a level I advanced beginner, level II competent nurse, level III proficient advanced professional nurse, or level IV expert professional nurse.
UEXCEL grants credentials to nurses to practice, provides a framework for performance evaluation based on the American Nurses Association’s (ANA) Standards of Clinical Nurse Practice, and supports clinical nurse career goal development through promotional advancement. Four categories of practice exist, with titles aligned to match the Magnet® Model components (reprinted here with permission):
- exemplary professional practice
- transformational leadership
- structural empowerment
- new knowledge, innovations, and improvements.
Key program elements
UEXCEL reinforces exemplary practice by using ANA standards, evidence in practice, and key program components. For example, UCH values reflect practice as a method for developing and enhancing critical thinking. Clinical narratives are required at all levels of practice.
- Level I nurse residents complete narratives throughout the program, reflecting on the complex issues facing newly licensed nurses.
- Clinical nurses who’ve chosen to advance from level II to III or from level III to IV must include a written narrative in their portfolio application that articulates a philosophy of practice and describes a clinical example of patient care reflecting skill acquisition at a higher level of practice.
- At the time of performance appraisal, clinical nurses at levels II, III, and IV come prepared to verbally reflect on practice using examples of care that highlight excellence at their practice level.
Research shows the most important issue for clinical nurses is working with competent peers. Reflective practice and peer review are two program components that leverage the expectation for clinical competency and patient safety.
Mentorship is another essential element of UEXCEL. At all practice levels, clinical nurses must set goals for the upcoming fiscal year and identify mentors to support them toward successful goal completion. UEXCEL requires nurses planning to advance to choose an advisor and sign the Intent to Credential Form, as well as obtain the nurse manager’s affirmation of support. Advisors complete a certification course to reinforce knowledge of the advancement process. They meet regularly with their mentees, as advancement criteria are rigorous using the four practice standards categories.
Structure for advancement
The UEXCEL advancement structure consists of two components:
- a published document listing the criteria required for applicants to advance
- a portfolio of achievements submitted by the nurse applicant to show how the criteria were met for peer review.
Criteria are organized into four sections, which match the four standards-of-practice categories.
Section 1: Exemplary clinical practice
This section requires a professional résumé, as advancement represents application for a new position as a clinical nurse III or IV. Requirements include recommendation letters from the nurse manager and a nurse peer; a copy of the BSN diploma or transcript showing active enrollment in a BSN, RN-to-MS, or RN-to-DNP program; and a copy of the fiscal-year performance appraisal documenting that the applicant exceeds at the current practice level. The applicant also must include a clinical narrative describing practice expertise with a clinical exemplar.
Section 2: Transformational leadership
For this section, the applicant showcases outcomes of a leadership project that improved the unit care-
delivery system or, for level IV applicants, a hospital-wide project. Examples of projects include implementing bedside shift report, initiating a unit newsletter, developing a unit staff-recognition program, and using the National Database of Nursing Quality Indicators® RN satisfaction survey data to improve staff satisfaction with meal breaks. Level IV project examples include implementing a new code lab labeling system in partnership with laboratory staff and working on a nurse-retention survey in partnership with the manager.
A second component of this section is revising or developing a policy, a standard of care, or patient-education materials. This and all other portfolio sections require a literature review to document evidence using the UCH system for analyzing levels of evidence.
Section 3: Structural empowerment
For this section, the applicant provides documentation of peer instruction, such as developing a continuing nursing education session, acting as preceptor to enhance onboarding of staff, or instructing student nurses. Unit community service activities also can be included. For example, a burn intensive care unit (ICU) nurse started a drive to collect socks for the homeless. Another nurse used national standards for Occupational Safety and Health Administration noise levels to develop a noise-reduction project in the postanesthesia care unit, and presented the successful outcomes nationally.
Section 4: New knowledge, innovation, and improvement
The final section highlights clinical nurse quality or research projects designed to improve patient care. Nurse unit-based projects may relate to the hospital’s critical success factors, such as initiating ICU bedside rounds to reduce pressure ulcer rates. Pre- and post-implementation FOCUS-PDCA model data must be displayed, with raw data collection forms included. (See Understanding the FOCUS-PDCA model by clicking the PDF icon above.)
Examples of projects for level III to IV nurses include implementing a preoperative call system for outpatient surgery and developing changes in preanesthesia do-not-resuscitate orders by partnering with surgeons to ensure patients and families are knowledgeable about decisions preoperatively. Journal clubs, part of this standard, document how review of evidence led to practice changes.
Program impact and innovations
While UEXCEL’s development spanned decades before the nursing practice culture changed, its results have extended far beyond expectations. UEXCEL member contributions to improving patient care and the profession are reflected in 47 posters and presentations to local and national meetings and 15 articles either published or accepted for publication in the past year.
UCH leaders have committed to nurse professional development by allotting time, fiscal resources, and supportive structures. The result is a dedicated workforce engaged in improving the quality and safety of patient care. Program innovations, driven by clinical nurse feedback using a valid and reliable UEXCEL evaluation survey conducted every 2 years, provide ideas, concerns, and issues that the board addresses. Changes are initiated after input from many stakeholders.
As the most recent innovation, we moved our portfolios from paper to a digital format—an initiative cited in the literature as media encouraging creativity and ease of use (led by co-author Amanda Nenaber). Level I nurse residents now use these media, as do most level II and III clinical nurse applicants. Our goal is for all UEXCEL members to initiate a professional portfolio to enhance their professional profile and document members’ accomplishments. Such innovations keep the program alive, strengthen professional nurse practice, and sustain our shared leadership model to enhance the Magnet work environment.
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The authors work at the University of Colorado Hospital in Aurora. Mary Krugman is director of Nursing Innovation and Outcomes. Michelle Rudolph is permanent charge nurse in a surgical unit and co-chair of the UEXCEL board. Amanda Nenaber is a clinical nurse specialist in the heart failure program. Carolyn Dietrich is a clinical nurse in the postanesthesia care unit.