Building a Clinical Ladder for Ambulatory Care

By Woolsey, Colleen; Bracy, Kate | Nursing Economics, January/February 2012 | Go to article overview

Building a Clinical Ladder for Ambulatory Care

Woolsey, Colleen, Bracy, Kate, Nursing Economics


* Finding innovative rewards for nursing service will be integral in meeting the challenges of future shortages of nursing staff.

* A clinical ladder is one tool worth exploring and perfecting to address those challenges.

* Exploration of a case study demonstrates a method for developing a clinical ladder.

* Steps and pitfalls in developing a clinical path are illustrated.

* Future uses, benefits, and opportunities for clinical ladders are suggested.

ALARGE WEST COAST HEALTH care system sought to increase retention of nurses and improve nur sing practice in the ambulatory care setting. The organization developed a clinical ladder program for inpatient nurses that contributed to meeting these goals. Although inpatient and ambulatory care nursing typically prioritize different skills, senior managers reasoned that since their acute care ladder was successful, a similar ambulatory care program would result in im proved nursing retention and level of practice.

Nursing shares skills and tasks across areas of service provision and populations. For example, almost all nurses assess patients' well-being. In the hospital setting nurses routinely assess physical status through vital signs and orientation to time and place. Community health emphasizes the integration of biopsycho- social needs while mental health focuses on psychological and psychiatric concerns. Ideally, all areas of nursing practice assess all of these facets. In ambulatory care, a complex nursing assessment integrates elements in ways distinctive from other practice settings.

Inpatient and ambulatory settings differ in several aspects of nursing practice; therefore, a definition lends clarity. For the purposes of this article, inpatient nursing is defined as providing care on a 24-hour basis in a hospital, skilled nursing facility, or correctional institution. The ambulatory care nurse, by contrast, provides hands-on care in an outpatient setting in which the patient enters and receives care within 8-14 hours and then returns home. To appreciate the unique challenges and opportunities in the development of an ambulatory care clinical ladder, the following case study is presented.

A Case Study

In 2007, a large Northern California health care system began developing an ambulatory care clinical progression program. The outpatient senior managers noted the ambulatory care nurses were hard to retain despite being highly capable. The managers also observed that, as a group, the outpatient nurses seemed dispirited. Management's solution was to develop and implement a clinical ladder system to promote retention, honor nursing excellence, and in so doing sponsor a spirit of optimism. Due to the success of this agency's inpatient ladder program, senior ambulatory care managers decided to implement a distinct outpatient clinical ladder. They hired a consultant to develop the clinical ladder program.

To begin their work, the consultant and the senior ambulatory care management team discussed the alignment of key organizational elements in support of the clinical ladder program. These included the agency's organizational mission, internal and external agency environments, and inclusion of all stakeholders in the ladder development process. At that point the senior managers framed the clinical ladder program as a "gift to line staff in recognition of their hard work." Essentially the management team decided that this "gift" would be a "surprise."

Despite the consultant's urging and much discussion, the ambulatory care managers did not understand the importance of stakeholder buy-in from the project's inception. Line staff and labor partners were not involved in project development. Nevertheless, the venture moved forward.

The senior management team considered several clinical ladder schema. These included Haas and Hackbarth's (1995a; 1995b) domains of nursing, Streeter's (2007) clinical advancement program, and Vanderbilt's professional nursing practice model (Robinson, Eck, Keck, & Wells, 2003). …

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