In 2000, in an effort to address the looming nursing shortage, Meridian Health set out to create sustained and positive changes to the nursing culture at the system's three hospitals which are located in central New Jersey. A key component of this cultural transformation was the development of a process for recognizing leadership and professional development of nursing staff.
Like many hospitals, Meridian had a clinical ladder program. Nurses first applied to participate, then advanced by reaching established benchmarks, including achieving advanced certifications, completing continuing education requirements, and attending staff and committee meetings.
Meridian's system leadership recognized that clinical ladder programs could promote nurses' professional and personal growth. However, they were concerned that the clinical ladder lacked a fundamental tenet—improved patient outcomes. Teri Wurmser, R.N., M.P.H., Ph.D., the director of Meridian's Ann May Center for Nursing, said that Meridian's clinical ladder program requirements were not tied to the care nurses delivered at the patients' bedside, nor did it document their expertise. For example, nurses could advance by attending a percentage of staff and committee meetings, but active participation, such as spearheading a quality improvement initiative, was not required.
Therefore, Meridian Health challenged its nursing leadership to develop a clinical recognition system that better reflected the expertise and leadership of nurses. To understand how hospitals create and sustain culture change in their institutions, the Robert Wood Johnson Foundation (RWJF) has funded Meridian and nine other hospitals to document their experiences in improving organizational culture. These lessons can help inform other hospitals interested in undertaking similar initiatives.
Meridian created a team to examine the existing clinical ladder structure and determine if it was at all aligned with the system's cultural transformation work. That team was comprised of Wurmser, the chief nursing officers at all three Meridian hospitals, the chair of the clinical ladder programs at each campus, representation from the nursing union at one Meridian hospital, other interested staff nurses, and an outside consultant. According to Wurmser, two questions guided the group—how do we truly document what nurses do at the bedside, and how should we reward nurses for their expertise?
Some problems were obvious. For example, attending a percentage of staff and committee meetings fulfilled a requirement, but participation at the meetings was not documented. Also, to reach the highest levels of the clinical ladder, nurses had to complete an independent research project that was unrelated to their work on patient care units, a task that did not interest many nurses at Meridian.
The team decided that all aspects of the recognition program must be linked to the care nurses provide at the bedside and to performance improvement initiatives. For more than a year, the team met to define levels of achievement and performance standards and competencies for each level, receiving feedback from frontline staff throughout the process.
In 2003, Meridian Health introduced a new system for rewarding the professional and leadership development of its nursing workforce—the Clinical Advancement and Recognition of Excellence (CARE) Program. Meridian nurses are eligible to apply to the CARE program after completing a three-month probationary period and one full year of employment. However, new hires learn about CARE during their orientation.
The application process is a distinguishing feature of the CARE program. Nurses no longer submit a list of activities and meetings in which they participated and continuing education credits that they have earned. Instead, applicants submit a written portfolio documenting evidence of how their work supports the cornerstones of nursing at Meridian Health, including clinical practice, education, shared governance and research. They also document how they possess the competencies of the clinical level to which they are applying.
"They are very proud of their portfolio after it's done. It's a lot of work," Wurmser said.
Applications and portfolios are reviewed quarterly by a committee of nursing peers, including at least one representative from each nursing unit. The committee uses specific scoring criteria and looks for evidence relating to patient care and improved patient outcomes.
Another hallmark of the CARE program is the financial reward to nurses. For every CARE level achieved, nurses receive a one dollar per hour increase in compensation. This is in addition to regular salary increases.
Four years into the program, nearly 60 percent of eligible nurses are enrolled, a higher number than participated in the former clinical ladder program. Wurmser attributes some of this to the overall cultural transformation work at Meridian.
"Because we introduce this at orientation, nurses know that CARE is something that is core - part of Meridian. All of our nurses know that we have this program. It's an expectation here at Meridian," Wurmser added.
Nurses are able to advance through the levels of the CARE program more easily than through the former system. Prior to the launch of CARE, Meridian's Jersey Shore University Medical Center saw more nurses attain the highest level of achievement than the other two Meridian hospitals. With the CARE program, an equal number of nurses across all three campuses are earning the highest recognition.
According to Wurmser, CARE nurses proudly wear pins on their uniforms and are happy to answer patient's questions about the program. Nursing units also display framed certificates of staff who have achieved CARE recognition. But perhaps most important, CARE has had a tremendous impact in demonstrating to Meridian's nurses the crucial role they play in quality improvement.
"Because nurses are putting information about quality improvement into their portfolio, it makes them more cognizant of their role in improving outcomes," Wurmser said.