A community hospital recognizes a need and builds a program to meet it.
- To recruit and retain a strong, competent nursing workforce, healthcare organizations must provide programs that support new nurses, beginning with onboarding and throughout their careers.
- The ideal clinical ladder program should engage nurses, be easy to understand and navigate, and adapt to changing needs.
- The purpose of PDAP is to encourage clinical nurses’ professional development and advance their individual practice.
Let us never consider ourselves finished nurses. We must be learning all of our lives.” This quote, attributed to Florence Nightingale, is especially relevant today as nurses seek working environments that provide professional growth and development through concrete orientation and new graduate residency programs, mentorships, and ongoing educational opportunities that promote clinical and critical thinking skills. To recruit and retain a strong, competent nursing workforce, healthcare organizations must provide programs that support new nurses, beginning with onboarding and continuing throughout their careers. (See Climbing the ladder.)
Recognizing a need
The ideal clinical ladder program should engage nurses, be easy to understand and navigate, and adapt to changing needs. Without these elements, the program won’t be sustainable. We learned that at our community hospital (Monmouth Medical Center) in 2015 when we realized that our decades-old program didn’t adequately reflect the work nurses were doing on the unit, hospital wide, and even in corporate activities outside of their nursing jobs.
Program survival required modernization that incorporated current healthcare trends and organizational standards. To revise the program, a team of nurse educators reviewed the literature and developed a tool based on Jean Watson’s Theory of Human Caring and the Clinical Caritas Processes. To apply to the clinical ladder programs, nurses were required to write a 250-word essay that described a positive patient outcome or experience. The goal was to give them autonomy and flexibility about how they would participate in the program.
The new program was presented at a hospital-based shared governance council, and modifications were made based on the council’s input. The new program launched in April 2016. All eligible nurses were encouraged to apply, and the clinical education department developed training and workshops to inform and engage staff and provide application process support. About 10% of eligible nurses applied.
After the initial excitement fizzled, the program’s success couldn’t be sustained; 2 years later, less than 2% of the nursing staff remained in the program. A significant challenge was that the program was primarily the responsibility of two clinical educators who didn’t have expertise in all subspecialties and struggled to understand what nurse research or performance improvement projects entailed. This was frustrating for both educators and staff.
To better understand the frustration and lack of interest, the education team conducted focus groups with nurses from different units and levels of expertise to investigate why they were leaving the ladder program. Nurses told us they found the program difficult to navigate and that it wasn’t concrete enough. They had difficulty writing narratives and found the application too vague. In addition, they felt the program was cumbersome and struggled to meet the criteria. Some nurses said, “Just tell me what to do and I will get it done.”
We also conducted focus groups with nurses who weren’t participating in the program and asked what prevented them from applying. They felt they had no time to complete the paperwork and that they didn’t know how to navigate the application to meet some of the criteria. Some more experienced nurses didn’t have a bachelor of science in nursing (BSN) degree (nurses in the program were required to have a BSN or be actively working toward it) and weren’t interested in enrolling in a college program at this stage in their career. Also, many felt the financial incentive wasn’t enough to make the program worth it.
The nursing educators reassembled in 2017 to once again review the clinical ladder program. We conducted a literature search to identify components of successful programs, and we reached out to other organizations in our health system to learn what made their programs successful. If we found a component we liked at a successful program, we obtained permission to duplicate it. We wanted to capture what nurses were doing to promote themselves professionally and how bedside nurses were enhancing quality patient care on a daily basis. We also wanted to recognize nurses who mentor and serve as positive role models for safe practice. We sought out nurses within the organization who were members of unit councils and shared governance to identify the critical elements of nursing practice and make sure they were reflected in the new program. And because our facility was on the American Nurses Credentialing Center (ANCC) Magnet® journey, we took the opportunity to align our program with the Magnet Model components.
Our literature review indicated that the success and sustainability of a program requires support from nursing leadership and administration. We met with our leaders to discuss the decreasing number of nurses in the program and to look at increasing the financial incentives. We shared what we envisioned for the new program, including a more professional name. The name was changed to Professional Development Advancement Program (PDAP).
In redeveloping our program, we acknowledged that the nursing staff comprised a wide range of experiences and four generations of nurses working at the bedside. In our literature review, we learned that nurses just starting their careers seek employment in supportive work environments that focus on quality and safe patient care. They want to be rewarded for their efforts, and they want employers to guide them as they transition into practice. These new nurses look to their employers to help them advance their skills, and they want opportunities to advance.
Mid- to late-career nurses want to remain employed in the profession if their work environment is positive and supportive of older workers. They want a professional culture that respects and recognizes their wealth of experience and dedication to their employers.
Considering these generational differences, we wanted our program to be relevant for all nurses personally and professionally.
Building the new program
The purpose of PDAP is to encourage clinical nurses’ professional development and advance their individual practice. The new program outlines the experience, critical thinking skills, education, and professional activities required of nurses seeking advancement. It provides nurses with opportunities for growth and development and a consistent framework for progress. And it’s designed so nurses at all levels and experiences can participate.
The program consists of four levels that are aligned with the ANCC Magnet Model components and focused on improving empirical outcomes. Nurses have opportunities to achieve points under each component; the number of points determines their PDAP level. By modeling our nursing practice around the Magnet components, the overall goal is to achieve nursing excellence by creating a culture that’s focused on delivering high-quality, evidence-based care, continual improvement of empirical outcomes, and greater patient and staff satisfaction. (See Point by point.)
PDAP incorporates Patricia Benner’s theoretical framework and Jean Watson’s philosophy. Together, they provide the outline for nurse professional growth and development and incorporate principles of the caring-healing environment. (See Putting theory into practice.)
Learning from the past program, all clinical educators are now responsible for nurses applying to the program in their respective areas of expertise, allowing the educators to provide better direction with project development and performance improvement. The educators follow their assigned staff more closely and help them stay on target with their projects. In addition, they encourage and mentor new staff applying to the program.
The education rollout took the entire summer of 2018. Education consisted of clinical educators attending unit council, shared governance, staff, and one-on-one nurse meetings. We also conducted informational sessions and workshops so nurses could ask questions and get help building and reviewing their applications. In addition, the educators guided nurses as they developed performance improvement projects and research. The initial feedback was positive, and staff felt that the new point system was easier to understand and more concrete than the previous program.
Our goal was to increase eligible nurse participation by 20%. We began accepting applications in the fall of 2018. We had 91 applications submitted and approved, meeting the 20% goal; participation increased by 30% from 2016 and by 911% from 2017.
Meeting nurses’ needs
Since the inception of the new program, feedback from staff has been positive, and 150 nurses currently are enrolled in the program (to date, no nurses have dropped out). Staff can apply quarterly, and we’re finding that each quarter new staff apply. We’ll continue to monitor the program and modify it as necessary to ensure it meets the needs of today’s nursing workforce.
The authors work in the Center for Professional Development, Innovation and Research at Monmouth Medical Center, Long Branch, New Jersey. Wendy Reich is a clinical educator, Danielle Hilliard is the administrative director, and Marybeth Gartland is a clinical educator.
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