In an effort to provide an equitable and systematic structure for recognizing excellence in clinical nursing and to encourage commitment to nursing professionalism, Catholic Medical Center (CMC) in Manchester, New Hampshire, chose to revamp its clinical ladder program and implement a new process in 2013. The resulting Professional Recognition Program (PRP) is proving to be both a vehicle for rewarding exemplary practice and a catalyst for inspiring nurse leadership and innovation. We also anticipate it will prove valuable as we strive to achieve ANCC Magnet Recognition®.

CMC’s former clinical ladder program was based on Dr. Patricia Benner’s novice-to-expert model. It focused on recognizing nurses whose clinical practice incorporated clinical excellence as well as strategies to enhance and enrich the clinical practice environment. The advancement process was one in which nurses, by choice, took the opportunity to showcase their clinical excellence. Their professional contributions to the practice environment were shown through preparation of a portfolio that included a clinical narrative, a unit-based or hospital-based project along with other requirements, and a dialogue with the Clinical Nurse (CN) Advancement Program Review Committee. Nurses had the chance to advance to a CN II or CN III and receive a 5% monetary bonus for each progression level.

The program succeeded, advancing an average of 24 RNs per year from 2001 to 2013. However, as time progressed, we realized that follow-up and the ability to ensure nurses maintained their practice level once they advanced on the ladder were hard to manage and enforce. The existing committee made several efforts to remedy the situation, but in late 2013, leaders decided to revamp the entire program.

Program design

Representatives from all nursing units were invited to participate in a rapid-action workgroup tasked with designing a PRP. The final group consisted of nine clinical nurses, one nurse educator, one nurse researcher, and two representatives from nursing administration. The group was charged with conceptualizing the program, developing all necessary paperwork, and planning for implementation.

The workgroup reviewed several recognition programs from other area hospitals and developed a program using the American Association of Critical-Care Nurses’ synergy model for patient care and Benner’s novice-to-expert model as its foundation. When designing the program, the committee sought to rectify challenges with the previous ladder program.

• Reinforcing CMC’s commitment to exemplary professional practice. At least 50% of RNs progressing through the previous ladder program had either nursing diplomas or associate degrees in nursing. The committee didn’t want to bar these highly valued staff members from applying to the new program. But it also sought to align with CMC’s goals of reaching an 80% bachelor of science in nursing (BSN) workforce by 2020, as well as satisfying Magnet Recognition Program® requirements. So we decided to require all RNs applying to the PRP to have at least a BSN, to be enrolled in a BSN program, or to be certified in their specialty area. These stipulations would help increase our RN certification rate—an organizational and nursing strategic goal. Additionally, the program would help give RNs who return to school an added monetary incentive and give nurses without BSNs a chance to be part of the program by obtaining their degree.
• Making the program more equitable. The committee developed a more systematic approach for RNs’ entry and progress through the program. The new PRP program would use a two-tiered bonus program structure that both recognizes and incentivizes clinical RNs to participate in activities that develop leadership, promote nurse autonomy, and improve patient outcomes. Under the new structure, nurses would reapply for the bonus program annually, eliminating the need for the committee to monitor continued compliance with the program.
• Developing a new RN compensation model. With the old clinical ladder program, nurses were “hired-in” at the CN I, CN II, or CN III level, taking into consideration their years of service and level of expertise at another hospital or organization without formal skill validation or competency assessment from CMC. This program allowed RNs to be hired at a higher pay rate. After many months of working together with nursing leadership, senior management, and the human resources and finance departments, the committee developed a new RN compensation model with broader compensation ranges, eliminating the need to use the clinical ladder system for increasing the pay scale.

Program structure

The previous clinical ladder program rewarded RNs with an emphasis on tasks, such as serving as preceptor to a new RN, taking the charge nurse role, or recommending policy changes. In this growing age of nursing role expansion and development, the committee sought to recognize and reward nurses for the critical role they play, the forward thinking they provide, and the initiative and innovative ideas they offer every day. So the committee tailored the types of activities rewarded to encompass broader conceptual-based processes. The new format would still acknowledge and give credit to RNs who were preceptors or were part of a policy change. But committee members believed adding these other areas would acknowledge the depth and breadth of today’s nurse.

At the same time, the committee aimed to reward commitment to the hospital’s strategic goals of developing exceptional people, achieving outstanding quality, offering superior service, providing financial stability, and sustaining growth and advancement. To accomplish this, the committee developed a document called the Professional Development Activity Points list—a list of activities with assigned point values. (See Professional Development Activity Points.)

To ensure that the Professional Development Activity Points List and coordinating bonus program structure would reward those already demonstrating exemplary professional practice while encouraging broader engagement in nursing professionalism, each committee member filled out an application and went through the peer-review process. Each member also surveyed members of their home unit to gauge fair and obtainable point ranges. Finally, the points system was analyzed for reliability using a statistical power analysis.

Program requirements

The committee decided all clinical nurses and clinical managers would be eligible to apply after completing at least 12 months of service to CMC. Applicants must:

• meet or exceed all expectations on their annual performance evaluation and obtain their director’s signature to validate their eligibility for recognition
• submit an application packet consisting of their Professional Development Activity Points List and a portfolio of supporting documentation
• submit a clinical exemplar reflecting on a clinical experience that demonstrates exemplary professional practice (first-time applicants only).

Applicants may apply to the PRP program on an annual basis. For each bonus cycle, the applicant reflects on the previous calendar year’s achievements and applies for the appropriate bonus level based on activity points achieved. (See Practice point requirements.)

Implementation

The transition to the new PRP program required a title change for all nurses. Under the old clinical ladder program, a nurse could be a Clinical Nurse I, II, or III. With the new program, every nurse would be called a Clinical RN, except new nurses, who would hold the title Entry RN for the first 12 months. Those who achieved PRP-2, PRP-3, or PRP-CNM (clinical nurse manager) status received a sticker stating their title, to be placed on their name badge.

Committee members educated all staff nurses and managers about the new program, its requirements, and the application process. During the application window, they worked with applicants to prepare their portfolios and answer questions about the program.

Since program implementation, PRP committee members’ role is to function as peer reviewers for portfolios submitted for each application cycle, serve as mentors for new applicants, and continually reevaluate and update the Professional Development Activity Points List to ensure the program continues to encourage commitment to organizational goals and highlight the breadth of nursing’s contributions and achievements to CMC.

Program impacts

The program is now finishing its second year. Applicants will be submitting second-year portfolios (for calendar year 2014) in late February 2015. The committee has started to look at metrics.

But exciting changes already are evident. In 2013, 18% of CMC nurses took part in the program, compared to an average 4% annual participation in the previous ladder program. Hospital wide, specialty certification for RNs rose from 16.9% in 2013 to 21.2% through September 2014. Also, CMC has seen increases in unit-based, nurse-led journal clubs, nurse-produced patient- and staff-education materials, and participation in unit-based and hospital-based committee work. Small successes such as these inspire confidence that CMC is headed in the right direction and that this program is meeting clinical nurses’ needs and furthering the organization’s strategic goals.

Selected references

Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA; Addison-Wesley; 1984.

Hardin SR, Kaplow R. Synergy for Clinical Excellence: The AACN Synergy Model for Patient Care. Sudbury, MA: Jones & Bartlett Publishers, Inc.; 2005.

The authors work at Catholic Medical Center in Manchester, New Hampshire. Emily Karwacki Sheff is coordinator of Nursing Practice and Standards and the Magnet Recognition Program. Jessica Fellman is a staff nurse in the intensive care unit. Jennifer Torosian is executive director of nursing.