Staff Nurses Perceptions of the Efficacy of a Healthcare System’s
Success through Excellence in Practice (STEPs) Clinical
Advancement Program
Linda Bartjen, Royce Peppa, Dana Villines
Advocate Lutheran General Hospital
Abstract:
Introduction: Limited research has been conducted to evaluate the efficacy and overall
nurse satisfaction with clinical ladder programs. Since 2004 a medium-sized
healthcare system has offered a clinical career advancement program: Success
Through Excellence in Practice (STEPs). The STEPs program was implemented to
enhance nurse retention, improve associate/employee satisfaction, and promote the
professional development of nurses along the continuum of novice to expert. Since
the inception of the program, the number of nurse applicants for STEPs promotions
has steadily decreased at many sites within this healthcare system.
Method: In this study, nurses who are eligible for STEPs were surveyed with the Clinical
Ladder Assessment Tool (CLAT) via Survey Monkey to determine their perceptions
of the program and to identify barriers that may deter them from applying for
promotion. Survey response rate was 25% (n = 1095) with 86% of the sample
responses from the Magnet hospitals (n = 942) and 14% of the sample responses
from the non-Magnet hospitals (n = 153).
Result: Overall, subjects at Magnet and non-Magnet hospitals reported high levels of
knowledge about and satisfaction with the STEPs program. However, Magnet
responses were significantly higher than non-Magnet responses, indicating higher
levels of knowledge and satisfaction than non-Magnet responses. Specifically,
questions related to Levels of the STEPs Program (p < 0.001) Guide for Evaluation
of Clinical Performance (p = 0.009), Assures for Professional Growth (p = 0.029),
Enhanced Job Satisfaction through Recognition for Clinical Performance (p =
0.041), and Perceived Rewards are Comparable with the Levels of Practice (p =
0.042) were statistically significant.
Methods:
Table 3: Statistically Significant Sub Scales of Responses*
Results:
Sample
All eligible nurses from four Magnet hospitals and four non-Magnet hospitals were asked
to participate in the survey (n = 4209) via an email that provided a link to a survey on
Survey Monkey.
Table 1: Employment and Education Demographics for Magnet and
Non-Magnet facilities
Magnet
N (%)
Eligibility
• being eligible for application to the STEPs program for promotion
• being at least a Nurse Clinician II level or above, delivering direct patient care
• being a permanent employee working at least 40 hours per 2 week pay period
Critical Care
258 (27.9 %)
This study was approved by the hospital’s Institutional Review Board. Completion of the
survey was voluntary, and all data was collected without identifiers.
Other areas
Initiation of the STEPs Program
The original clinical ladder process was initiated in a medium-sized healthcare system comprised
of four Magnet and seven non-Magnet hospitals. Major goals were to foster professional growth
of the RN’s, provide the opportunity for skill development, recognize clinical excellence, and
offer monetary compensation for those seeking promotion. Like most clinical ladders, the process
was an alternative to promotion into administrative or educational roles. Designed to be selfpaced, the program encourages individual nurses to define their practice and assume personal
responsibility for their career development. The clinical ladder is based on Patricia Benner’s
work, From Novice to Expert: Excellence and Power in Clinical Nursing Practice (1984), which
describes advancement through years of experience based on the Dreyfus model for skill
acquisition. The STEPs program recognizes four levels of practice with defined criteria that
demonstrate competency at each successive level (i.e., Nurse Clinician I, II, III, & IV).
Consideration for advancement requires that the applicant meet the criteria set by the Clinical
Career Advancement Board (CCAB).
Although the STEPs program had been underway since 2005, it was unclear how this program has
impacted RN satisfaction, retention and promotion. Anecdotal evidence suggested that the STEPs
program was underutilized within this healthcare system and no systematic data was available to
evaluate this theory. Presuming that most RNs would desire promotion and compensation for
promotion, other barriers such as being unfamiliar with the STEPs program, not fully
understanding the requirements of the program or disbelief that participation in the program will
lead to employment growth might explain why this program is underutilized. The purpose of this
study was to determine the perceptions of nurses who are eligible for promotion and to identify
barriers related to application into the program.
66 (43.7 %)
419 (43.5 %)
45 (28.5 %)
519 (56 %)
65 (43%)
31 (3.3 %)
5 (3.3 %)
392 (40.7 %)
83 (53.7 %)
Masters of Science, Nursing
Other education levels
Steps Levels
5.62±16.43
5.03±1.881
< 0.001**
Steps Reinforce
2.86±1.518
2.64±1.589
0.117
Steps Guide
2.89±1.488
2.53±1.506
0.009**
Steps Assures
5.20±2.185
4.75±2.258
0.029**
Steps Perceived
2.86±1.446
2.58±1.504
0.042**
Steps Enhanced
1.83±1.484
1.57±1.325
0.041**
Steps Provides
4.50±2.156
4.24±1.325
0.203
*Higher scores indicate more positive attitudes
**Significant P value; Student’s t-test
Current Level Achieved Within the Steps Program
Nurse Clinician II
Introduction:
Healthcare facilities devote many resources in staff time and salaries to support clinical
advancement programs; yet, there is weak evidence in the literature to support or refute
the value or efficacy of career advancement processes (Drenkard, 2005). Additionally,
little research documents how these programs meet professional development,
satisfaction, recruitment and retention goals (Schoessler, 2005). However, emerging
research suggests that Magnet facilities with clinical ladder programs have better nurse
retention and satisfaction than non-Magnate facilities (Kramer, et. al, 2008.)
265 (28.6 %)
Bachelor of Science, Nursing
• Overall: n = 1095 (25%)
• Magnet hospitals: n = 942
• non-Magnet hospitals: n = 153
non-Magnet
hospitals
14%
P Value
42 (27.8 %)
Level of Education Completed
Survey response rate
Nurse Clinician III
Registered nurses who provide direct patient care account for the single largest
percentage of the work force in hospitals and healthcare systems (Bureau of Labor,
2009). The current nursing shortage, expected to be exacerbated by the healthcare
demands of the aging baby boomer generation, requires that measures be taken to
promote nurse retention in a more competitive nursing market place and in an effort to
ensure optimum patient care outcomes
(http://www.aacn.nche.edu/Media/pdf/NrsgShortageFS.pdf).
Non-Magnet
N (%)
Non Magnet
Mean ± SD
Clinical Area of Nursing Practice
Women’s & Children
Conclusion: Reasons given for seeking advancement included professional
advancement and financial rewards and barriers to seeking advancement included
time constraints and concerns of increase workload/ responsibilities.
Magnet
Mean ± SD
746 (80.6 %)
120 (79.5 %)
162 (17.5 %)
29 (19.2 %)
34 (1.9 %)
4 (1.3 %)
Nurse Clinician IV
CLAT sub-Scale scores were summed (Yes = 1; No = 0) and compared between groups via
Student’s t-test (Table 3). Potential subscales can range as follows: Levels (0-7), Reinforce (0-4),
Guide (0-4), Assures (0-7), Perceived (0-4), Enhanced (0-4) and Provides (0-5). Mean scores
were relatively high for all subscales except for Enhanced indicating that STEPs availability
would not influence employee attraction or retention. The responses were statistically significant
between Magnet and Non-Magnet hospitals in all Sub-Scales except for the “Reinforce” and
“Provides” Sub-Scales.
Magnet
hospitals
86%
Figure 1: Survey response rate by hospital nursing designation
Instrument
Demographic information such as area of nursing practice, the number of years of
experience, the respondent’s position on the clinical ladder and level of education was
collected. The Clinical Ladder Assessment Tool (CLAT) was used with permission to
measure the effectiveness of clinical ladder programs (Strzelecki, 1989).
Subscales:
o areas of differentiation of levels of nursing clinical competence (Levels)
o reinforcement of responsibility and accountability in nursing practice (Reinforce)
o guide for evaluation of clinical performance (Guide)
o opportunity for professional growth (Assures)
o rewards and benefits commensurate with levels of practice (Perceived)
o job satisfaction through recognition for clinical practice (Enhanced)
o provision of increased levels of autonomy and decision making (Provides)
Strzelecki (1989) established inter-judge reliability, content and construct validity; in
addition to a test/re-test reliability of 88 percent which was established through a test and
retest process using a convenience sample with twenty five nurses.
Two qualitative questions were added to assess why subjects were or were not
participating in the STEPS program.
The largest area of responses came from the Critical Care and Women’s and Children’s Nursing
Divisions in both Magnet and Non-Magnet hospitals (Table 1). At all facilities, the level of Nurse
Clinician II and Nurse Clinician III were greater than 98%, with Nurse Clinician II level at 80%.
More nurses were prepared at the Baccalaureate and Master’s level at the Magnet organizations
than at the non-Magnet organization. Magnet designation did not impact the number of years of
nursing experience or the number of years worked at these organizations, with more than half of
the respondents having 17 or more years experience in the profession, and more than 11 years in
their current healthcare system (Figure 2).
- Main reasons reported for participating were:
o personal growth
o professional advancement
o recognition
o monetary rewards
-Main reasons reported for not participating were:
o perception of an increased workload and responsibility
o the application process was too time consuming/ cumbersome
o lack of desire to complete the paper / project required for Nurse Clinician III and IV levels
20
18
17.1±11.4
17.8±10.7
Conclusions:
16
1. In general, nurses at Magnet institutions reported more knowledge of the STEPs
program and more satisfaction with the program than nurses at non-Magnet
institutions, although reported knowledge and satisfaction at both were high.
13.1±9.9
14
11.5±9.1
12
2. All subscales indicated a good understanding of the STEPs program and an ability to
seek and obtain advanced skills and promotion, but lower scores on one subscale
(Enhanced) indicates that STEPs is not a high priority when seeking advancement in
employment or in retention.
10
8
6
3. It is curious that the majority of respondents believe that the program offers them an
opportunity to be recognized by their peers and to be promoted, but that the program
is perceived as undesirable by their peers. This conflicting finding may contain the
essence of why RNs are underutilize this program, but the rationale for this cannot be
empirically determined from the data in this study.
4
2
0
Years of Experience in Nursing
Magnet
Years Worked Within This System
References:
non-Magnet
Data Analysis
Data was stored and analyzed using SPSS 14® (Chicago, IL). Demographic information
and survey results are presented as means with standard deviations or as counts with
percentages as appropriate. Survey comparisons between Magnet and non-Magnet
responses were analyzed using t-tests with statistical significance determined at p < 0.05.
In addition to the forced-choice questions, qualitative questions about why the subjects were or
were not participating in the STEPS program were included.
Figure 2: Employment Experience Means for Magnet and Non-Magnet facilities
1.
2.
3.
Benner, P. (1984) From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley.
Drenkard K, Swartwout E. (2005) Effectiveness of a clinical ladder program. Journal of Nursing Administration, 35(11), 502-506.
Kramer M, Schmalenberg C, Maguire P, Brewer BB, Burke R, Chmielewski L, Cox K, Kishner J, Krugman M, Meeks-Sjostrom D, Waldo M. (2008) Structures and practices
enabling staff nurses to control their practice. Western Journal of Nursing Research, 30(5), 539-559.
4.
Schoessler M, Akin R, Boyd R, Falconer K, Kaiel C, Moore-Stout DL, Payne R, Sajko C, Sawyer L. (2005) Remodeling a clinical ladder: an action research design. Journal
for Nurses in Staff Development, 21(5), 196-201.
5.
Strzelecki S. (1989) The development of an instrument to measure the perceived effectiveness of clinical ladder programs in nursing: A dissertation submitted to the
Temple University Graduate Board.
Web references:
1. Retrieved on March 12, 2009 from Bureau of Labor Statistics, http://www.bls.gov/oco/ocos083.htm
2. Retrieved on March 12, 2009, American Colleges of Nursing: nursing fact sheet, from http://www.aacn.nche.edu/Media/pdf/NrsgShortageFS.pdf