The impacts of career ladder system for nurses in hospital

Abstract

Objective

To examine the impacts of the career ladder programme on nurses’ job satisfaction.

Method

We did a systematic review of the literature from 2008 to 2018. Data were collected from five databases (EBSCO, ProQuest, SAGE Journals, and Science Direct), using the keywords of nursing career ladder, job satisfaction, and clinical ladder.

Results

Sixteen articles were included in the review. The results showed the impacts of the career ladder system for the nurses in hospital were: (1) career advancement, (2) development of mentorship, (3) establishing an effective reward system, (4) skill and education development, and (5) awareness of duty. Development of mentorship and career advancement were shown to influence the development of nurse competency significantly.

Conclusions

Mentorship and career advancement had the largest impact on the nurses’ career ladder implementation. Nurse managers have a substantial role in improving the implementation of the career ladder in order to enhance nurses’ satisfaction.

Introduction

Nurses’ professional commitment is of vital importance to improve health care delivery and organization.¹ One form of support for nurses’ professional commitment is through the development of nursing career ladder system; a plan of nurses’ placement based on their expertise. Such system provides good opportunities to enhance the nurses’ competence and potential.² The nursing career ladder also contributes to making sound decisions about patient care, patient safety, policies and procedures, satisfaction, and health service reformation.³ The nursing clinical career ladder system has been implemented in several countries.²

The perception of the career ladder programme is one of the most influencing factors of job satisfaction and nurse turnover rates.⁴ Improving the nurses’ perceptions of the implementation of the career ladder necessitates support from the leaders and peers.⁵ The higher the nurse's perception of the career level, the higher the job satisfaction and the lower the turnover rate.⁴ In addition, the nurse's career level also increases the nurses’ awareness of tasks, nurses’ education, and patients’ recovery.⁶ The nursing career ladder provides clarity on task hierarchy, transparency in career progression, as well as facilitating expertise, and rewards.⁷

It is critical to know how the nursing career ladder can improve job satisfaction. The career ladder clarity, competency regulation, and reward system based on the nurses’ careers will clarify nurse competencies. Nursing career ladder programmes have a significant influence on patient quality and safety, which is the heart of nursing practice.⁸ Thus, the study objective was to examine the career ladder programme pertinent to nurses’ job satisfaction.

Method

A review of literature was conducted. The articles were searched using online databases: EBSCO ProQuest, SAGE Journals, and Science Direct. Different keyword combinations included ‘career’, ‘career ladder’, and ‘satisfaction’. Literature selection was determined based on the following inclusion criteria: (1) a focus on career ladder system in hospital, (2) a publication date between 2008 and 2018, (3) a study sample consisting of nurses at hospitals, and (4) cross-sectional, exploratory, article based on review studies. Exclusion criteria were articles that used anyone other than nurses as the study sample, such as nursing students or doctors.

Results

Initially, 183 articles in EBSCO, 4097 in ProQuest, 236 in SAGE Journals, and 216 papers in Science Direct were found (n = 4754). Screening on the titles and abstracts of the articles left 43 articles to undergo a full-text retrieval. However, we excluded 27 articles that did not match our inclusion criteria. Therefore, we eventually included 16 articles in this review (Fig. 1).

Figure 1.

Article selection process.

The included articles were of various research designs including cross-sectional,^1,4,9–11 mixed-method,^12–14 case study,² review article,¹⁵ non-experimental,⁹ and pilot project^3,7,16–18 (Table 1). We extracted five factors of the nursing clinical career ladder system that manifested in nurses’ job satisfaction.

Table 1.

Characteristics of studies reviewed.

Category	N	%
Sample country
USA	10	62.5%
Korea	3	18.75%
Taiwan	2	12.5%
Indonesia	1	6.25%
Design
Review	1	6.25%
Mixed-method	3	18.75%
Cross-sectional	5	31.25%
Non-experimental	1	6.25%
Case study	1	6.25%
Pilot project	5	31.25%
Instrument
Previously validated, literature reference	10	62.5%
Previously used, literature reference	1	6.25%
Self-constructed, no mention about a pilot study	5	31.25%
Theory
Discussed	13	81.25%
Not discussed	3	18.75%
Publication date
2008–2013	8	50%
2013–2018	8	50%

The result of this article are five points there are; Development of mentorship,^3,6,9 Career Advancement,^1,4,12,15, Establish an effective reward system,^12,13,16 Skill and education development,^15,17 Awareness of duty^4,6,13 (Table 2).

Table 2.

The impacts of career ladder (n = 16).

Category	n	%
Career advancement^12,4,15,1	6	37.5%
Development of mentorship^3,9,6	4	25%
Establish an effective reward system^12,13,16	3	18.75%
Skill and education development^15,17	2	12.5%
Awareness of duty^4,6,13	1	625%

Development of mentorship

The career ladder is useful in developing mentorship and creating a collaborative work environment. The career ladder is divided based on education, ability, and experience.^3,9,13,18 Nurses with more experience and skills can share their knowledge with nurses with fewer skills.^3,6 Nurses are empowered and guided to undertake advanced training in ways that are easily understood and accepted by their peers.^13,18 The nursing career ladder system is a comprehensive nursing resource management system that can improve the quality of nursing by categorizing the novice nurse's expertise to become more experienced.^4,7 In many national and international healthcare institutions, preceptorship programmes are available for all nurses.¹⁹

Career advancement

The career ladder programme has profound influences on improving nurse qualification, thereby promoting nurses’ career advancement.^4,6,7,12,15 Two studies found that 30.9% of the factors that affect job satisfaction consist of the perception of the career development system, number of hours worked, personal desire for growth, and awareness of experience.^4,6 The other studies reported the evaluation of the career level programme shows which found no direct dissatisfaction with the career ladder programme among the majority of nurses, who were satisfied with the career ladder system applied in the hospital.¹² Nursing career ladder system is a way to create an organizational climate that encourages nurse retention. Nurses who are aware of their beneficial career paths are less likely to leave.^20–22

Establishing an effective reward system

The nursing career ladder programme rewards the nurses for their education, skills, research and leadership ability, which have a positive effect on the nurses’ satisfaction, staff retention rates, and patient outcomes.^6,13 In addition, the rewards encourage evidence-based practice, critical thinking, and knowledge development in nursing practice. It is essential to recognize expert practices because such recognition promotes the quality of care and makes nursing contributions visible at all levels of the organization.¹⁶ A professional nursing career developed in the form of a ladder program allows for a system that enhances performance and professionalism through improvement initiatives in accordance with the training and practice. The career ladder systems also test the nurses’ competency in carrying out accountable and ethical nursing care according to the limits of authority.^{1,2,4,7,9,11–14}

Skill and education development

Nurses have the skills needed to contribute to a healthy work environment, to support professional, and to influence patient care and outcomes. Skill and education development are necessary to improve nurses’ competencies in promoting the patients’ safety. Nurses must develop their skills so they can manage various groups of patients, complex patient care be it in the chronic or acute condition.²³ Career level programmes can have a positive impact on nurses’ contributions to their organizations as well as improving their professional skills.⁹ Half of the studies in our review state that the nursing career ladder programmes are associated with increased responsibility, accountability, knowledge and skills.^{2,3,6,7,10,11,13,15–18}

Awareness of duty

Professional nurses are expected to be able to think rationally, to accommodate environmental conditions, to know themselves, to learn from experience and to be self-actualized so that they can improve their positions on the professional career ladder. Studies found more positive attitudes towards career ladder programmes and their related benefits.^9,13 For nurses, professional self-awareness is essential in developing achievement portfolios and applying to the next step of the career ladder. Nurses are encouraged and guided to describe the level of advanced training in the ways that can be understood and accepted. This creates significant awareness in fostering nurses as professionals in the provision of nursing care.^18,20,24

Discussion

Our systematic review shows that five impacts of the nursing career ladder in the United States, Taiwan, Korea and Indonesia (Table 3). Career ladder management can effectively improve the nurses’ job satisfaction rate at various steps and therefore can advance the quality of care and management efficiency.^4,15,25 As for the relationship among willingness to exert effort, assessment in continuing a person's career, confidence in goals and values, inner satisfaction, and external satisfaction, the results of the study indicate that the willingness to exert effort correlates significantly and positively with assessment in continuing one's career (r = 0.77, p < .01).

Table 3.

Type of career ladder among countries.

Countries	Type of career ladder
USA	Career ladders are determined based on four domains, namely: nurse novice, advanced beginner, competent, and expert. Level I or novice nurses are freshly graduated nurses or nurses with no work experience. Level II nurses are nurses who have mastered their skills and have excellent power of decision-making. Level III is the advanced nurse who functions independently. Level IV is an expert nurse with a comprehensive educational knowledge and skills based on experience
Korea	Developed a model to evaluate nursing professionalism, which determines the clinical ladder system levels, and verified its validity
Taiwan	The hierarchy of the nursing career ladder is not integrated. The division is determined by considering the characteristics of each medical institution and department, ability, degree (level of recognition of professional and technical capacity), educational background, seniority, work experience, and professional ethics
Indonesia	Each nurse career development at the Hospital and Primary Services has 5 levels of clinical nurse. The clinical nurse ladder allows the transition of career ladder to nurse managers, nurse educators, or research nurses

The gap between career needs and development programmes made significant (p < 0.01) contributions to organizational commitment (β = −0.029) and turnover intention (β = −0.453).²⁶ The career ladder classifies the level of nursing professionalism and rewards as essential human resource tools for managing nursing.^4,6,12 In line with that result, another study said it refers to the hierarchical division of care practice that is based on individuals’ educational background, experience, capabilities, professional training, and work performance.¹⁵

The career ladder programme can survive. The key is to follow the learning cycle of identifying goals, changing plans, taking action and evaluation processes.⁵ The success of a career ladder depends on many factors, including supportive leadership, the nurse's ambition, and the committee members who play a role in implementing the programme.¹⁶ Some studies state that effective career paths and competencies can increase recruitment and retention of experienced staff, develop professionalism, create an effective reward system to improve performance, strengthen the quality of nursing practice performance and value the performance of nurses who have clinical advantages.^23,27

A nurse's career ladder consists of implementing the mentorship, making decisions, policies and procedures, and excellent patient health service reforms. Consistently, other studies suggest that the clinical ladder can function as mentor and preceptor to the nursing staffs.^3,4,9 Another studies also state that to achieve a successful clinical ladder system, a support system is needed to help nurses understand the career path through education, mentoring, and satisfaction surveys and interviews.¹⁰

The nursing career ladder programme provides levels of financial incentives, increased job satisfaction, recruitment help, and recognition of nurses for better performance. Nurses who have a career beneficial to the organization tend not to leave.^4,7,15,20 From the financial side, the career ladder programme has a significant impact on increasing hospital incentive costs. However, lifting the nurses’ turnover and re-hiring costs will require far more money. Nurses’ career advancement is closely related to the incentive scale. The implementation of the career ladder programme will provide motivation and rewards to the staff.^2,4,6,12,16 The awards given to nurses for following the levels of the career ladder will increase the nurses’ job satisfaction.^4,14,16

Some of the above factors should become the concerns of hospital institutions, especially as those factors concern nurse satisfaction. Nursing managers must also play substantial roles in implementing and improving the career ladder system, especially in facilitating the nurses’ improvement of their abilities. These measures will undoubtedly improve the quality of the career ladder system's implementation in health services. Implementing the career ladder programme would increase the competence, recognition and nursing authority in nursing care.^2,28

Conclusions

The career ladder programme is an exceptional investment. The development of mentorship and career advancement are some of the impact of the career ladder programme's implementation. Nurse managers have a substantial role in improving the implementation of the career ladder in order to improve job satisfaction among nurses.

Conflict of interests

The authors declare no conflict of interest.

Acknowledgments

This work is supported by Hibah PITTA 2018 funded by DRPM Universitas Indonesia No. 1852/UN2.R3.1/HKP.05.00/2018.