Research progress of hierarchical division in nursing ladder management in China

Yong-Le Shi,Ji-Ping Li

West China Hospital,West China School of Nursing,Sichuan University,Chengdu,Sichuan 610041,China

Review Article

Research progress of hierarchical division in nursing ladder management in China

Yong-Le Shi,Ji-Ping Li*

West China Hospital,West China School of Nursing,Sichuan University,Chengdu,Sichuan 610041,China

A R T I C L E I N F O

Article history:

Received 3 April 2015

Received in revised form

3 January 2016

Accepted 17 June 2016

Available online 15 September 2016

This paper reviews the concept,research condition and research progress of hierarchical division in nursing ladder management in China;points out the problem and outlook of this area.

Nursing ladder management

Hierarchical division

Nursing staff

1.Introduction

With the rapid economic development of and continual increase in citizens'health needs,many hospitals and nursing managers across China have begun to deepen the reform of the nursing work mode,thereby advancing and improving nursing ladder management.Here,we examine the hierarchical division in nursing ladder management in China.Ouranalyses mayprovide a reference for the reform and development of nursing practice.

2.Concept

Nursing ladder management refers to hierarchical division for care workers that is based on individuals'educational background, experience,capabilities,professional training,and work performance.Correspondingly,an entry and promotion system should be established,which may include incentives in salary,responsibility, and academic status,thereby boosting work enthusiasm and core competence.Consequently,the quality of clinical care and patient satisfaction can be improved.1-3

3.Brief history

3.1.Studies of nursing ladder management in other countries

In 1964,Creighton in the US was the first to propose the concept of clinical ladders.In 1972,Zimmer recognized the importance of nursing ladder management for nursing outcome and the administration of nursing human resources.1,2Subsequently,the concept was gradually introduced into clinical practice and the administration of nursing human resources.1,2However,nursing ladder management had not been widely applied in the recruitment, training,and promotion of nursing professionals until the 1980s. Afterwards,consistent with the development of the nursing industry,ladder management also entered a stage of a continuous innovative cycle of improvement and application.It has been revealed that ladder management can effectively address nurse shortage issues and the high turnover rate,improve the job satisfaction rate of nurses at various ladders,and,therefore,advance the quality of care and management efficiency.

3.2.Studies on nursing ladder management in China

Nursing ladder management in China began in the 1980s and was officially proposed by the Ministry of Health.In 2005,the Ministry of Health published the“Developmental Guideline of Nursing in China,2005-2010”.This guideline formally stated thatvarious levels of health institutions should effectively integrate nursing job duties,technical requirements,and the ladder management of nurses to enable various levels of nurses to fully play their roles.3In 2012,the Ministry of Health issued the“Developmental Guideline of Nursing in China,2010-2015”,in which the“Nurses Ordinance”proposed the following goals:strengthening the building of nurse teams according to the law,elevating the clinical care capacity,accelerating the training of core nursing specialists,and improving nursing management.4In recent years, various major medical institutions have been actively involved in the reform and improvement of nursing ladder management, which has been in accordance with the requirements of the Ministry of Health and has taken into account the fundamental conditions of China.This endeavorhas led toa continuous optimization in the team structure of nursing staff and an improvement in nursing quality and the rate of patient satisfaction.5

4.Current research status

4.1.Research status in foreign countries

It has been reported that there is a considerable turnover rate among nurses and that high-level nurses have a greater satisfaction rate than their low-level counterparts.6In addition,newly recruited nurses have a relatively high turnover rate due to their poor job satisfaction rate.7These findings illustrate an extraordinary problem of human resource management in medical communities worldwide.8To address this problem,many developed countries have begun to employ nursing ladder management,which was pioneered in the United States.1The clinical ladder mode proposed by Benner classifies nurses into the following five levels of experience:novice,advanced beginner,competent,proficient,and expert.Each level has its corresponding job responsibilities,and this classification system provides a basis for the future development of nursing ladder management.In addition,other medical institutions employ clinical ladder modes in the three different fields of clinical practice,nursing management,and nursing education;in nursing education,these modes are mainly divided into the following four levels:N1,N2,N3,and N4.N1 and N2 refer to the internship.In the N3 stage,individuals are assigned to specific fields,such as the management field,and N3 refers to assistant head nurse.N4 refers to matron.There are also advanced modes in the other two fields.1,2

In 2000,the Department of Health of the United Kingdom formulated the National Health Service Knowledge and Skills Framework(NHS KSF),whereby a nursing ladder system that correlated remuneration with promotion was established.NHS KSF has been incorporated into the health reform.The ladder system in the UK categorizes nurses into eight ladders,and each ladder is subdivided into A,B,and C levels.Ladders 1-4 correspond to assistant nurses;6 and 7 correspond to registered nurses,8 to senior nurses, and 8C1 to nursing specialists and nursing experts.In addition, professional development projects at all levels are planned,and corresponding training is provided.Furthermore,a multidimensional assessment of core abilities is conducted for nursing staff annually.The assessment results are used as the basis for promotion and remuneration.2,9,10In Canada,the nursing classification uses educational background,job experience,and the level of technical recognition to categorize nurses into non-registered care workers, enrolled nurses or assistant nurses,and registered nurses.11,12

4.2.Research status in China

Studies of nursing ladder management in China started later than they did in developed countries and remain in the exploratory and developmental stage.Research on ladder classification is mainly focused on the laddering basis and the establishment of capacity levels.13Wan et al14employed qualifications and actual work performance to categorize nurses in intensive care units into the following three levels:specialized nurses,executive nurses,and care workers.The system clarifies job responsibilities and formulates a performance assessment system for individual positions. Nevertheless,the system has an oversimplified and unclear setting for the capacity levels.According to the requirements of the“Developmental Guideline of Nursing in China,2005-2010”and the“Management criterion of nursing in Guangdong Province”,Lv et al15proposed a step-by-step implementation of a nursing ladder management system that introduces five levels of nurses,namely, matron,specialist nurse,senior primary nurses,junior primary nurses,and assistant nurses;in addition,criteria for admission eligibility are established accordingly.Taking“Primary studies on nursing ladder management-Shanghai Municipal Commission of Health”as reference,Zhen et al16proposed a hierarchical division plan that takes into account the hierarchical access standards of nurses,the capacity standards,the job content of different levels of nurses,and the actual circumstances of a hospital.Specifically, based on a comprehensive review involving work performance, obstetrics work experience,job title,and educational background,a matron classifies nurses into the following five levels:matron, specialist nurse,primary nurse,associate nurse,and assistant nurse.In addition,the matron should refine the job responsibilities and job contentand establish the correspondingevaluation criteria. However,this hierarchical division plan lacks relevant competitive mechanisms.Based on the requirements of the“Management criterion of nursing in Guangdong Province”,the team structure of undergraduate nursing staff,and the nursing hierarchy established in the ward according to patients'conditions,Shi et al17propose a scheme consisting of matrons,care leaders,primary nurses,and associate nurses and that stresses that care leaders are in charge of nursing quality control,thereby augmenting the work efficiency and quality of nursing.Furthermore,Shi et al17also suggests the selection requirements and processes for a care leader.Based on educational background,work experience,and clinical care performance,Zhao et al18introduced a three-level mode consisting of the care leader,the primary nurse,and the assistant nurse in emergency wards and intensive care units as well as a two-level mode consisting of the care leader and the primary nurse in emergency rooms and outpatient visits.In addition,Zhao et al18 also suggest that,when developing the nursing ladder,attention must be paid to the formation of echelons with regard to age,titles, work performance,and education background and team members must complement each other in personality and interests.These measures can boost coordination and cooperation.Moreover,it has been argued that nursing ladder management should be executed such that positions are competed for on a basis that is open,fair, and just,thereby maximizing the match between the nursing staff and job positions.Liu et al19argued that,in recent years,few reports have been devoted to a stratified position setting based on titles and that the title is merely one of the factors in determining the ladder.Furthermore,ladder management plans are mostly dictated by supervisors who rely on a regional-based literature and the experience of nursing managers to create ladder systems, which lack a theoretical basis or evidence that is consistent with the conditions in China.By examining the status of nursing ladder management in China,Shi et al20suggest that there are issues in this type of management.For example,a hierarchical division is accompanied by problems related to the insufficient capacity of high-level personnel and unclear duty specifications within a level. These arguments provide a reference for future progress and improvement in nursing ladder management.

Medical institutions in China have non-unified systems of hierarchical division in nursing ladder management.The hierarchical division is mainly based on the basic requirements issued by the Ministry of Health on nursing planning;in addition,subdivision is performed by taking into account the traits of individual medical institutions and departments,abilities,title(degree of recognition of the professional and technical capacity),educational background,seniority,work experience,and professionalethics. Designing capacity levels mainly includes the ability hierarchy of management(nursing director-departmental head nurse-ward head nurse-care leader)as well as ability hierarchy of clinics (specialist nurse-primary nurse-assistant nurse-etc.).Nursing ladder management can enhance the utilization efficiency of nursing human resources,which leads to human-position compatibility and improves the quality of care and management efficiency.21-23Moreover,nursing ladder management also offers a well-defined career advancement system for nurses.In other words,the skills, knowledge,and comprehensive ability of nurses may exhibit continual improvements with increased professional status,which helps boost their job satisfaction rate and sense of accomplishment. Ultimately,nursing talents are retained and the turnover rate is decreased.21,24-26

5.Problems in and the outlook on the hierarchical division of nursing ladder management in China

The major problems in hierarchical division in China are summarized as follows:first,the hierarchical division of nursing ladder management has its main basis in years of experience,but it lacks a corresponding theoretical and tangible foundation.2Thus,it is necessary to integrate the experience of ladder management and nursing development,in addition to human resource problems in China and abroad,thereby exploring a unified model of nursing ladder management that is suitable for most medical institutions,which should exhibit a scientific theoretical and tangible basis as well as great feasibility and controllability.27-29Second,the hierarchy division is relatively broad and lacks proper subdivision.2,27Under the umbrella of a unified model, individual medical institutions should comprehensively review their own features and limitations to establish a refined ladder management that is compatible with their own development.For example,tertiary institutions and township clinics have extraordinary differences in their overall medical environment as well as their patient populations.Therefore,their refined nursing ladder management models are likely to display tremendous divergence. Third,the hierarchical division has a low clinical feasibility,e.g., issues such as the relatively low clinical performance of nursing staff with a high educational background may restrict its clinical feasibility.This problem should be addressed by taking into account the backdrop of a large medical environment,which may be accomplished through the following measures:first,it is crucial to ensure well-coordinated,multi-pronged development in nursing education,nursing management,clinical practice,and nursing research;second,it is necessary to establish scientific and factually based nursing ladder management as well as a comprehensive system for nurse recruitment,induction,training,and promotion; third,upon conducting nurse recruitment,training,and promotion,it is important not only to first address the work requirements of nursing but also to consider the expertise,wishes, and needs of individual nurses.27-29Moreover,because the quantity and quality of care workers are intrinsically related to the quantity and conditions of patients,medical institutions should offer sufficient study opportunities to nourish the knowledge and skills of care workers and help them better adapt to the job.30,31Importantly,relevantqualitycontrolsystemsmay also be introduced to improve the clinical suitability and feasibility of such management models.32

6.Conclusions

Nursingladdermanagementhasprofoundinfluenceson improving nurses'qualifications,promoting their career advancement,augmenting care outcomes,and enhancing the rate of patient satisfaction.Hence,the hierarchical division of nursing ladder management should fully take into account the overall circumstances of China and take successful cases and experiences in China and abroad as reference,which will be further aided by continuous exploration and improvements.These measures may help solve the problems in China's nursing ladder management,optimize nursing human resources,and enhance the efficiency and quality of work, which will propel continuous progress in nursing practice in China. In addition,regarding hierarchicaldivision,itis crucialto strengthen the basic study of the ladder structure,thereby producing will-defined classification systems.Finally,the clinical feasibility of such systems can be elevated by comprehensively examining the specifics,taking a case-by-case approach if necessary,and also taking into account the intrinsic relationships of individual factors.2

Conflict of interest

All contributing authors declare no conflicts of interest.

1.Schmidt LA,Nelson D,Godfrey L.A clinical ladder program based on Carper's fundamental patterns of knowing in nursing.J Nurs Adm.2003;33: 146-152.

2.Shi LP,Zhang YF,Li R.The current application status of the nursing clinical ladder program.Chin Nurs Manage.2012;12:87-88(in Chinese).

3.National Ministry of Health.Developmental guideline of nursing in China, 2011-2015.Chin J Nurs.2012;47:286-288(in Chinese).

4.Xu J,Wang CY,Wang XW.Current status of nurse grading management and the corresponding measures.Hosp Manage Forum.2013;30:36-38(in Chinese).

5.National Ministry of Health.Developmental guideline of nursing in China, 2005-2010.Chin J Nurs.2005;4:721(in Chinese).

6.Cho SH,Lee JY,Mark BA,Yun SC.Turnover of new graduate nurses in their first job using survival analysis.J Nurs Scholarsh.2012;44:63-70.

7.Bj?rk IT,Hansen BS,Samdal GB,T?rstad S,Hamilton GA.Evaluation of clinical ladder participation in Norway.J Nurs Scholarsh.2007;39:88-94.

8.Riley JK,Rolband DH,James D,Norton HJ.Clinical ladder:nurses'perceptions and satisfiers.J Nurs Adm.2009;39:182-188.

9.Cote DA,Burwell KT.A revised nephrology nurses'clinical ladder.Nephrol Nurs J.2007;34:243-248.

10.Pierson MA,Liggett C,Moore KS.Twenty years of experience with a clinical ladder:a tool for professional growth,evidence-based practice,recruitment, and retention.J Contin Educ Nurs.2010;41:33-40.

11.Drenkard K,Swartwout E.Effectiveness of a clinical ladder program.J Nurs Adm.2005;35:502-506.

12.Winslow SA,Fickley S,Knight D,Richards K,Rosson J,Rumbley N.Staff nurses revitalize a clinical ladder program through shared governance.J Nurses Staff Dev.2011;27:13-17.

13.Shi LP,Ye JX,Liao SH,et al.Probe into establishing a nursing level architecture for new hospitals under medical reform background.Chin Nurs Res.2012;26: 643-645(in Chinese).

14.Wan JL,He YF,Liu GY,Liao J,Zhang JY.Application of hierarchical nursing management in a central ICU.China Med Herald.2007;4:77-78(in Chinese).

15.Lv CX,Liang LM,Liu XX,Lin GF.A preliminary exploration of nursing staff layer management in the ward.Chin Nurs Manage.2009;9:48-50(in Chinese).

16.Zhen XF,Yu YC,Wang PM,Zhao LN.Application study of nursing ladder managementinamaternityward.ChinGenNurs.2010;8:1844-1846 (in Chinese).

17.Shi HQ.The practice of the nursing group head in nurse in tier management. Mod Hosp.2011;11:116-117(in Chinese).

18.Zhao Y,Song LN,Guo Z.The methods and reflections of implementing hierarchical management model in emergency departments.Guide China Med. 2012;10:385-386(in Chinese).

19.Liu JY.Research progress in nursing ladder management in China and the United States.J Nurs.2013;20:17-19(in Chinese).

20.Shi LP.A comparative study on the human resources structures of nursing between China and the United States.Int J Nurs.2009;28:1473-1475 (in Chinese).

21.Watts MD.Certification and clinical ladder as the impetus for professional development.Crit Care Nurs Q.2010;33:52-59.

22.Lv YH.The effects of nursing ladder management on improving nursing quality.Jilin Med J.2012;33:1315(in Chinese).

23.Niu XF,Wang CK.Probe into hierarchical management for improving obstetric care quality.Chin Nurs Res.2011;25:2801-2802(in Chinese).

24.Ko YK,Yu S.Clinical ladder program implementation:a project guide.J Nurs Adm.2014;44:612-616.

25.Helitzer DL,Newbill SL,Morahan PS,et al.Perceptions of skill development of participants in three national career development programs for women faculty in academic medicine.Acad Med.2014;89:896-903.

26.Paplanus LM,Bartley-Daniele P,Mitra KS.Knowledge translation:a nurse practitioner clinical ladder advancement program in a university-affiliated, integrated medical center.J Am Assoc Nurse Pract.2014;26:424-437.

27.Wang YF.Research progress of nursing ladder management.Contin Med Edu. 2014;28:47-50(in Chinese).

28.Hu YN.Research progress in management of graded nurse staffing levels.J Nurs Sci.2012;8:95-97(in Chinese).

29.Zhang J,Ding CY,He H,Zhang XY.Status quo and research progress on nurse hierarchical management.Chin Nurs Res.2014;28:267-270(in Chinese).

30.Kendall-Gallagher D,Blegen MA.Competence and certification of registered nurses and safety of patients in intensive care units.Am J Crit Care.2009;18: 106-113.quiz 114.

31.Park M,Lee JY,Cho SH.Newly graduated nurses'job satisfaction:comparison with allied hospital professionals,social workers,and elementary school teachers.Asian Nurs Res Korean Soc Nurs Sci.2012;6:85-90.

32.Chassin MR,Loeb JM,Schmaltz SP,Wachter RM.Accountability measures-using measurement to promote quality improvement.N Engl J Med. 2010;12(363):683-688.

How to cite this article:Shi Y-L,Li J-P.Research progress of hierarchical division in nursing ladder management in China.Chin Nurs Res. 2016;3:109-112. http://dx.doi.org/10.1016/ j.cnre.2016.06.012

*Corresponding author.

E-mail address:JP-Li@163.com(J.-P.Li).

Peer review under responsibility of Shanxi Medical Periodical Press.

http://dx.doi.org/10.1016/j.cnre.2016.06.012

2095-7718/?2016 Shanxi Medical Periodical Press.Publishing services by Elsevier B.V.This is an open access article under the CC BY-NC-ND license(http://creativecommons. org/licenses/by-nc-nd/4.0/).

?2016 Shanxi Medical Periodical Press.Publishing services by Elsevier B.V.This is an open access article under the CC BY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).