The roles of advanced practice providers – nurse practitioners, nurse anesthetists, clinical nurse specialists and physician assistants – continue to evolve. This article uses the acronym APP to encompass these four professions. Successful role integration for an APP includes promoting professional advancement and growth to maximize organizational contributions and personal job satisfaction.
The first year of any APP role is primarily devoted to achieving clinical competence. Following completion of this initial transition stage, the journey begins toward achieving professional success in the role and contributing to the mission of the organization.1 Ongoing evaluation and measurement to assure that the APP position meets organizational, service and individual professional needs is critical to success.2
An Incubator of Change
Akron Children’s Hospital, which has 78 locations throughout the Great Lakes region of Ohio, has increased its APP staffing by 60% since 2011, when a center for advanced practice was established and a director was named. The system includes a 253-bed campus in downtown Akron and a 32-bed campus in Boardman. Akron Children’s medical staff consists of 700 providers, of which more than 170 are APPs. At the time the center for advanced practice was established, measures for APP professional growth and advancement had not been formalized.
In 2011, a group of APN and PA leaders and directors from across the country came together for a conference to discuss a variety of professional issues facing APPs and healthcare delivery. The group considered a proposal for the creation of a standardized APP advancement model. This proposal cited a 2009 article3 about APN satisfaction in a veterans health system, in which respondents stated they were least satisfied with professional growth and intrapractice collegiality.
The group discussed the fact that at many institutions, APP practice is measured by tools created to evaluate physicians and RNs – tools that do not take into consideration the unique functions of APPs. Several institutions have taken steps to provide a model specific to this group of providers, but the majority of APPs are left trying to fit into other types of provider models.
This conference spurred members of the APP Council at Akron Children’s Hospital to establish an appropriate professional advancement model (PAM). Their vision was to develop a model that could serve as a national standard. In January 2012, this group successfully launched a PAM for APPs at Akron Children’s Hospital. This article describes that process.
We reviewed the literature for articles about PAMs. These articles helped us identify chief components of a PAM, and we used the information to shape our proposed model. Most of the articles referenced described nursing advancement models. PA advancement was discussed in only one article.4
The scope of a professional nurse clinical ladder is described in the literature5 as a reward for experience and competence allowing for retention and improved patient care.
Pye and Green6 proposed that leadership and empowerment are strong factors in APN retention. Clements and Parrinello7 described a ladder with a clinical track and a leadership track, each with two tiers. Clinical nurse specialists and nurse practitioners developed the clinical track; the leadership track was developed by a task force of administrative and managerial nurses.
The pertinent ladder variables identified were professional practice; care delivery; clinical coordination; and presentations and publications.
The Strong Memorial Hospital model8 identifies five domains in which APPs function: direct comprehensive patient care; education; research; system support; and publication and professional leadership. Ackerman8 described a conceptual model developed with the intention of providing an advanced practice framework for other institutions, which led to the development of a center for APNs.
A group of NPs and PAs in a neonatal intensive care unit (NICU)4 described a ladder model with three levels. Criteria for each were based on educational degree, years of professional experience, educational hours, number of presentations, and research. This resulted in pay increases in addition to annual merit increases. In addition to human resources staff, decisions were made by the division administrator, the NICU medical director and members of the clinical ladder committee.
Another article9 described a ladder with eight tiers and four tracks combining APPs and nursing staff. The highest achievable level for an NP was the RN VII clinical level. The tracks consisted of management, clinical, education and development. This system was developed to try to decrease a troubling staff turnover rate of 30%, and the ladder contributed to a 65% reduction in staff turnover within 2 years of implementation.
We reviewed PAMs developed at institutions in Northeast Ohio, including The Cleveland Clinic, University Hospitals of Cleveland Rainbow Babies and Children’s Hospital and Metro Health System. We also reviewed a PAM from Kaiser Permanente Health systems. Several commonalities were evident. All have three levels of professional attainment. Years of professional experience are the initial criteria for entry into a level. The models are each divided into four main categories: clinical practice, clinical education, publication and research, and leadership. The interpretation and value weighting of each of these categories differs among institutions.
The clinical practice category incorporates evaluation of skill and patient and provider outcomes. Outcome criteria are determined by peer review, supervisor review, patient outcome data, patient satisfaction surveys and quality improvement measures. All models cite practitioner involvement in health promotion and prevention activities. Clinical skills are also evaluated by documentation and participation in innovative practice development to ensure that APP practice is current and state-of-the-art.8 Two models incorporate measurable clinical innovations as a criterion for advancement in clinical practice. And productivity as a benchmark for clinical practice is included in two models.
Clinical education focuses on assisting in the development of staff, peers, community and universities. This may include participation in established educational offerings at the institutional, local, community, regional or international level, or in the development of new educational programs in each of these areas. Evaluation of the education component includes serving as faculty members at local universities and medical institutions. Mentorship of junior staff within the APP’s department or preceptorship with affiliated universities is an expectation within all models.
Dissemination of information is evaluated in the publication and research component. The APP is evaluated for his or her participation in continuing education, professional articles in a peer-reviewed journal and publication of original research. Presentations and lectures are also considered in this component.
Leadership is a key component of advanced practice. In the models we reviewed,4,6-9 examples of leadership ranged from participation at an institutional level to global involvement within the APP’s profession or specialty. This may be leading a team or developing a new role within the APP’s department, leading a committee within the institution, or serving on committees involved in institutional, community, regional or national policy development.
In one of the models, acting as a team leader on a committee that examines patient outcomes is criterion for the highest attainment level.
To achieve a better global perspective of the importance of each variable identified in these PAMs, we created a survey to examine the importance of the variables as well as the importance of a model as a whole.
The goal of the Advanced Practice Provider Professional Advancement Model Committee was to acquire input from as many APPs as possible in order to develop a model that would meet their needs. In spring 2012, we distributed our nine-question survey to 15 hospitals throughout the country. Institutional Review Board approval was obtained from the initiating institution. The survey was created in Survey Monkey and was open for 1 month. The survey questions represented the concepts defined by other models and the issues we foresaw in integrating these concepts into a nationally applicable model.
Three hundred twenty-four respondents began the survey and 201 completed all questions. Most APPs said they were in favor of a PAM. Respondents gave highest ratings to the factors that were most heavily weighted in existing models.
The respondents said they viewed clinical practice and leadership as the most important aspects of their careers; 66.2% said they felt this variable should be the most important factor on an advancement model.
The other components identified by respondents reflect the work APPs perform. The review of literature and review of other models demonstrated that APPs are involved not only in clinical practice, but also in educating staff and new providers. This work occurs locally and at national levels. Research is often part of the APP role and their involvement is sought and encouraged. These activities allow for leadership roles as well. These factors are all components that contribute to the advancement of a provider in a PAM.
The initial data compiled did not look at title (e.g., nurse practitioner, clinical nurse specialist, physician assistant) or the respondent’s institution. Based on feedback from the initial questionnaire, we launched a second survey at the Advanced Practice Provider Leadership Summit in September 2012. This survey received responses from 561 providers; 75.8% were NPs and 13% were PAs. The other respondents were clinical nurse specialists, nurse anesthetists and nurse midwives. The second survey provided a more thorough look at respondents. The results shadowed those of the first survey, validating our initial conclusions.
Based on our research and experience, we created a template for Akron Children’s Hospital (see table). This PAM contains three tiers: novice, junior and senior. The criteria for each level are spelled out and a recommended point system exists to weigh each contributing factor.
Recommendations about advancement include years of practice, maintenance in current tier for a minimum of 2 years, and compensation for each level as follows:
Novice: 2% to 4% increase from baseline, 4 hours added to education/conference hours
Junior: 4% to 6% increase from baseline, 8 hours added to education/conference time, 4-hour/pay period protected time
Senior: 6% to 8% increase from baseline, 12 hours added to education/conference time, 8-hour/pay period protected time.
The National Advanced Practice Provider Professional Advancement Model Committee reviewed our model in spring 2013. The committee approved of the model and agreed to push it forward into practice.
It is our recommendation that this model be used as a template and a national standard to evaluate and promote the practice of APPs.
Successful APP role integration and satisfaction requires a commitment to professional advancement by the APP body, administration and collaborating physicians. Collaborating physicians and APP peers play an important role in fostering the development of novice APPs and ongoing advancement of seasoned APPs. A PAM is an objective tool to effectively measure accomplishments and contributions within an institution. A model for professional advancement allows for role definition with clearer expectations and guidelines for ongoing growth.
1. Bahouth Mona, et al. Nurse Practitioner Orientation: The transition. In: Transitioning Into Hospital Practice. 1st ed. New York. Springer Publishing Company; 2013: 19.
2. Bryant-Lukosius D, DiCenso A. A framework for the introduction and evaluation of advanced practice nursing roles. J Adv Nurs. 2004;48(5):530-540.
3. Faris JA, et al. Job satisfaction of advanced practice nurses in the Veterans Health Administration. J Am Acad Nurse Pract. 2010;22(1):35-40.
4. Lutes J. A clinical ladder for NNPs. Neonatal Netw. 1998;17(8):47-48.
5. Torstad S, Bjork T. Nurse leaders’ views on clinical ladders as a strategy in professional development. J Nurs Manag. 2007;15(8):817-824.
6. Pye S, Green A. Professional development for an advanced practice nursing team. J Contin Educ Nurs. 2011;42(5):217-222.
7. Clements J, Parrinello K. Climbing Higher: An expanded career ladder creates opportunities for nurse managers and advanced practice nurses. Nurs Manage. 1998;29(12):41-45.
8. Ackerman MH, et al. Creating an organizational model to support advanced practice. J Nurs Admin. 2010;40(2):63-68.
9. Monarch K. From Theory to Practice . a career ladder that works. J Nurs Staff Dev. 1994;10 (4):202-206.
Ann Stratton is a nurse practitioner at Akron Children’s Hospital in Akron, Ohio. Kristen Breedlove is a physician assistant, Dianne Kulasa-Luke is a nurse practitioner and Julie Tsirambidis is a nurse practitioner at the same hospital. Gretchen Brandon is a nurse practitioner at Children’s National Medical Center in Washington, D.C.