Magnet(TM), Clinical Ladder, and Hospitals: Getting More for Less

 

Glowing nurses. So diverse. Young, old. Thanks to nursingworld.org for the picture that I borrowed.

Today, I’m going to write one of the most controversial professional articles in nursing. If one goes to Duck Duck Go and searches “Magnet hospitals” or “Clinical ladder for nursing”, one will see nothing but article upon article about professional advancement. Even going back 10 years, there are many websites devoted to how Clinical ladder programs (CLPs) make for “better nurses” and “better hospitals”. There are many articles about programs at different hospitals. There are pictures of glowing nurses, talking about their blessed profession, talking about how fulfilled they are by being able to give more. It helps them to become better nurses and make better hospitals.

I’m going to share a secret: it doesn’t.

Not really. Well, not necessarily.

While Magnet hospitals may have better outcomes, there are a number of factors at play: these hospitals are larger, better funded, and can do things to draw better staff. These hospitals have better outcomes partially because they have better equipment. These hospitals are regularly funded by either government grants or gracious generosity from the community; money isn’t everything, but it certainly helps.

In the meantime, CLPs emphasize employees doing more for the hospital in exchange for a bonus or a one-time percentage raise. From the Administrative side, this is wonderful! Nurses are often paid a pittance as their “raise” each year; I know my hospital (which is generous!) doesn’t even keep up with inflation. Nurses who start working with my level of experience regularly start at a rate higher than I enjoy; despite my decade of experience and loyalty to the same facility. Like many other jobs, the only way to get a raise, really, is to leave and come back later. But what if one doesn’t want to leave? What if one wants immediate recognition of clinical experience or education?

Herein lies the bribery of The Clinical Ladder.

The Magnet model (trademarked by ANCC), includes “empowerment” and “clinical practice”. Hospitals then use their CLP as an example of how nurses are able to have their own autonomy, empower themselves, continue education, expand professional development, participate in quality improvement, etc, etc. It’s a double whammy. While nurses spend countless hours preparing projects (quality improvement or otherwise; sometimes true research) and education programs for their peers in their non-clinical time, they have to continue doing these things every year. One must continually educate oneself, get new (expensive) certifications, become a relief charge nurse, do other projects, etc. in order to stay on the ladder. What exactly does that mean? In order to not have the raise taken back (at the current percentage, mind you), the Clinical ladder nurse must continue giving at the same rate. Every. Single. Year.

Oh. COVID-19, you say?

Ah! Does not matter. Did you do your charitable contributions? Did you make your poster? Did you recertify? Did you do a lengthy year-long project along with education? Did you document all of it? Did you update everyone monthly, quarterly, and yearly? Did you update the website? Did you fill out all the required forms? Did you take pictures?

Ah. Good. Well then, I guess you can stay.

Borrowed from acp-online.org, all rights are theirs, I just liked the picture.

In the meantime, the hospital is receiving free advertisements (charity while wearing hospital shirts; not paid, but may still contribute toward the ladder) and free work. Educators are being assisted in education. People are spending money on their own supplies to make posters; the hospital isn’t paying for the labor or the supplies (although they would likely insist that they will; the process is a pain and not worth the complaints about overtime or documentation). It makes the hospital look good; these projects can have pictures taken and have the documentation sent to ANCC for Magnet Certification!

While life is falling apart (as an example: I lost two family members last year, one this year already, and developed various new and exciting health issues), one must maintain one’s previous level of involvement. This includes committees, of course! You have to demonstrate your devotion to the hospital and ongoing quality improvement, right? One must email summaries of these meetings to the entire unit, present at staff meetings, etc. If life is falling apart, so be it. Clinical ladder waits for no nurse. If it’s too much, maybe you shouldn’t be on the ladder (insert guilt here). You can reapply later, when you’re more capable of fulfilling your responsibilities.

But in the meantime, in the middle of hardship, the percentage is lost (because you’re not doing the extra work that is required for that one-time raise that you got).

I can see why hospitals like CLPs so much. There’s a lot of extra work that is basically free after the first year. It creates examples for Magnet. It helps to promote research and other quality improvement projects that would otherwise require hiring more people. It’s much cheaper just to bribe one’s own employees to do more with less and then do more after that. It makes the hospital look good. It promotes research that many nurses wouldn’t otherwise want to do. It promotes involvement in the hospital. It makes the hospital look like there is upward mobility and some standards for why some nurses make more than others, not just the usual garden variety favoritism. It makes the hospital look like there are scientific standards and that nursing isn’t just about doing the job, consistently, day to day. It is about science and standards. It is about innovation. Future. It is about revolutionizing healthcare! It makes every nurse feel more responsible and promotes buy-in.

There’s really almost no downside for the hospital, except for the money, of course. Even so, a one-time 5% raise? Cheaper to give 10 of those than to hire a full-time quality control nurse. Cheaper to give 10 of those, than to hire a full-time nurse researcher. Cheaper to give another 10 of those, than to pay according to experience, loyalty, and things that only accrue over time without providing extra benefit to the hospital. It’s so much more cost-effective; it’s attractive to newer nurses who could get a 10% raise, right off the bat by having their BSN and a certification (as well as a council and various extra works over the year). It looks great from the outside, it helps with certifications, it’s extra work for cheap… there’s just no real downside.

Except for the nurses.

While the hospitals give lip service to “work-life balance”, they also tell you to control your career and advance yourself. Ah, but without new degrees or different jobs, the only way is the ladder! Which mandates more work.

And takes one away from life.

But this is all okay as long as nurses continue to identify personally as nurses, rather than human beings and people; they will see themselves as a part of a greater calling. As long as nurses identify as nurses first, they will continue to give even to their own detriment. As their mental and physical health fails, their spouses age, and their children graduate from school, nurses will re-evaluate this stance. By then, it will be too late for them.

They will have given the best years of their life and the best of their lives to their hospitals. Their energy, their faith, their optimism, their health, their lives will have been spent in service to their patients, but even more, to their hospitals.

And in exchange, they’ll get a small percentage (once) and maybe a pin. Oooh. Maybe a hospital-branded mug or water bottle.

But damn, if it isn’t cost-effective!

Published in Healthcare
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  1. RushBabe49 Thatcher
    RushBabe49
    @RushBabe49

    I’m familiar with this routine.  Employers boast about how their employees volunteer in the community; you do all the work, they take all the credit.  I quit doing any company-sponsored volunteer projects.  I volunteer on my own time, and I get the credit.

    • #1
  2. TheRightNurse Member
    TheRightNurse
    @TheRightNurse

    RushBabe49 (View Comment):

    I’m familiar with this routine. Employers boast about how their employees volunteer in the community; you do all the work, they take all the credit. I quit doing any company-sponsored volunteer projects. I volunteer on my own time, and I get the credit.

    Yes, but when it’s the only way to get a raise (and it also reflects nicely on the yearly eval)… that’s what happens.  Now, I genuinely like my hospital.  I like a majority of the doctors.  I prefer how it is run to how other hospitals are run.  Is it perfect?  Of course not (see above).  But it’s fairly good.  I’m perfectly happy to be a good example for them and to give them a human face in the community.

    Hell, I’d do that without getting paid.

    BUT, since they make it the only way to increase pay in any substantial form that one can control?  It’s really irritating and a number of people do not want to do it.

    • #2
  3. Postmodern Hoplite Coolidge
    Postmodern Hoplite
    @PostmodernHoplite

    This sure seems like a heckuva racket for the hospital administration. A one-time payment in exchange for a years’-long open-ended commitment to provide enhanced benefit to the organization for no further cost? What am I missing here? Meaning, why would nurses sign-up for this?

    (Okay…I’m pretty sure I know the answer to the question, “why?” I have dear friends and family who are career nurses, and these women stand head and shoulders above average, normal humans when it comes to having a heart for service.)

    • #3
  4. Matt Balzer, Imperialist Claw Member
    Matt Balzer, Imperialist Claw
    @MattBalzer

    RushBabe49 (View Comment):

    I’m familiar with this routine. Employers boast about how their employees volunteer in the community; you do all the work, they take all the credit. I quit doing any company-sponsored volunteer projects. I volunteer on my own time, and I get the credit.

    Eh, my previous employer had a couple programs where you could do it during work hours, meaning you get paid for it and they’d give you a lunch at the end, so there was a little incentive to sign up. 

    • #4
  5. Basil Fawlty Member
    Basil Fawlty
    @BasilFawlty

    Matt Balzer, Imperialist Claw (View Comment):
    Eh, my previous employer had a couple programs where you could do it during work hours, meaning you get paid for it and they’d give you a lunch at the end

    The free lunch is tempting but unnecessary.

    • #5
  6. JosePluma, Local Man of Mystery Thatcher
    JosePluma, Local Man of Mystery
    @JosePluma

    I never started on the clinical ladder because it didn’t have anything to do with nursing.

    I would occasionally discover a problem and work up a solution to it.  I’d then develop and deliver an educational presentation at preshift and staff meetings.  Because of my previous experience in law enforcement, I became involved in the employee safety committee and started teaching crisis intervention.  My bosses kept saying “You should be on the ladder with all the extra stuff you’re doing.”

    The one year I tried it, I got turned down because, among other things, I didn’t do a poster presentation.  Usually, I’d see a problem, then attempt to fix it.  But that didn’t happen regularly.  As a result, you had to go looking for problems.  One nurse did a presentation challenging a way that we give IV medications.  When I asked her what she based this on, it turned out to be one article in a nursing magazine.  Most of the staff just ignored the recommendation.

    I wrote a series of emails highlighting different principles of employee safety and crisis prevention.  I’ve shared some of them here on Ricochet.  Because these weren’t a “poster presentation” they didn’t count.  90% of the ladder is not the actual output, it’s documentation or other things that have nothing to do with nursing.  

    • #6
  7. Matt Balzer, Imperialist Claw Member
    Matt Balzer, Imperialist Claw
    @MattBalzer

    Basil Fawlty (View Comment):

    Matt Balzer, Imperialist Claw (View Comment):
    Eh, my previous employer had a couple programs where you could do it during work hours, meaning you get paid for it and they’d give you a lunch at the end

    The free lunch is tempting but unnecessary.

    It was better than the lunch I would have made for myself. Also I didn’t have to make lunch.

    • #7
  8. Percival Thatcher
    Percival
    @Percival

    Posters? For crying out loud, I haven’t made a poster since junior high, and I was pretty salty about it then, too.

    I do occasionally put up signs in the lab.

    “One of these lines is 240V triple-phase. If you don’t know which one, don’t touch any of them.”

    • #8
  9. TBA Coolidge
    TBA
    @RobtGilsdorf

    It’s funny how ‘girl jobs’ tend to involve making posters, baking, and working after hours for free, and how this sort of thing goes on regardless of liberation and equality. 

    • #9
  10. navyjag Coolidge
    navyjag
    @navyjag

    Another great one TRN.  With a real personal touch based on the last few days. The medical financing stuff I have been pondering for almost 60 years since Medicare financing was the big HS debate topic in 1963.  But on my first vacation in 2 years (OK, a family memorial) wife gets a possible blood clot.  Her doc thinks a tendon issue. As luck would have it, a nephew at the memorial, an ER doc in Illinois, says get to Emergency room asap. Then  a clear blood clot diagnosed. No flight home.  1700 mile drive West on I-40. No problemo.  On blood thinners and should be ok.  Good bless the nurses and ER folks at Norman, Oklahoma Regional Hospital.  Is there a fund we can donate to?

    • #10
  11. Matt Balzer, Imperialist Claw Member
    Matt Balzer, Imperialist Claw
    @MattBalzer

    TBA (View Comment):

    It’s funny how ‘girl jobs’ tend to involve making posters, baking, and working after hours for free, and how this sort of thing goes on regardless of liberation and equality.

    From what I’m given to understand posters are a major component of certain post high school education. You could ask @hankrhody, all I know is that when he went to tech school he was regularly talking about the posters that he was having to make.

    • #11
  12. JustmeinAZ Member
    JustmeinAZ
    @JustmeinAZ

    JosePluma, Local Man of Mystery (View Comment):
    As a result, you had to go looking for problems.

    Good grief. You had to go and remind me of Six Sigma (this was in the Aerospace industry) in which every single employee was required to participate. So everyone in a department had to identify a potential process improvement and write it up and get it signed off by every manager above you. A lot of crap came out of that.

    • #12
  13. TheRightNurse Member
    TheRightNurse
    @TheRightNurse

    JustmeinAZ (View Comment):

    JosePluma, Local Man of Mystery (View Comment):
    As a result, you had to go looking for problems.

    Good grief. You had to go and remind me of Six Sigma (this was in the Aerospace industry) in which every single employee was required to participate. So everyone in a department had to identify a potential process improvement and write it up and get it signed off by every manager above you. A lot of crap came out of that.

    Ugh.  LEAN.  Belts.

    UGH.

    • #13
  14. HankRhody Freelance Philosopher Contributor
    HankRhody Freelance Philosopher
    @HankRhody

    Matt Balzer, Imperialist Claw (View Comment):

    TBA (View Comment):

    It’s funny how ‘girl jobs’ tend to involve making posters, baking, and working after hours for free, and how this sort of thing goes on regardless of liberation and equality.

    From what I’m given to understand posters are a major component of certain post high school education. You could ask @ hankrhody, all I know is that when he went to tech school he was regularly talking about the posters that he was having to make.

    In grade school they call it a science fair. When you get older they call it a conference. Really it’s much the same thing.

     

    • #14
  15. Al Sparks Thatcher
    Al Sparks
    @AlSparks

    I’ve never worked in either nursing or teaching — both “girl jobs” — and am an occasional outsider looking in.  But when I read about this program and an emphasis on posters when doing presentations, I’m reminded of how teachers are often evaluated on their classroom bulletin boards.  Apparantly a lot of time is spent in college education programs on bulletin boards.

    I vaguely recall my mom complaining about it.

    The emphasis on committee work seems to be another commonality of those two trades (or “professions”).

    • #15
  16. HankRhody Freelance Philosopher Contributor
    HankRhody Freelance Philosopher
    @HankRhody

    JustmeinAZ (View Comment):

    JosePluma, Local Man of Mystery (View Comment):
    As a result, you had to go looking for problems.

    Good grief. You had to go and remind me of Six Sigma (this was in the Aerospace industry) in which every single employee was required to participate. So everyone in a department had to identify a potential process improvement and write it up and get it signed off by every manager above you. A lot of crap came out of that.

    Yeah. This. Seeing a problem and fixing a problem helps everybody. Demanding that you see problems and fix problems on a set schedule means you have to make up problems, and that helps nobody.

    Really the Industrial Engineering types who ought to be handling lean manufacturing should know better. If you keep every machine in an assembly line running at full capacity all the time you’re going to create backlogs of partially completed work at various steps, which is a problem in a number of ways. This is a fundamental insight of the discipline; I wonder why it doesn’t get applied more often to people. 

    • #16
  17. HankRhody Freelance Philosopher Contributor
    HankRhody Freelance Philosopher
    @HankRhody

    HankRhody Freelance Philosopher (View Comment):

    Matt Balzer, Imperialist Claw (View Comment):

    TBA (View Comment):

    It’s funny how ‘girl jobs’ tend to involve making posters, baking, and working after hours for free, and how this sort of thing goes on regardless of liberation and equality.

    From what I’m given to understand posters are a major component of certain post high school education. You could ask @ hankrhody, all I know is that when he went to tech school he was regularly talking about the posters that he was having to make.

    In grade school they call it a science fair. When you get older they call it a conference. Really it’s much the same thing.

    When I went back to college the second time each year we’d make and present a poster at a conference in the Twin Cities. This conference was  a collaboration between UWM and a handful of tech schools like ours which had more enthusiasm than serious research, but whatever, it was a fun time. As part of our coursework we students would band together like brigands and do a research project. My second year there we went with the topic of “Growing Graphene”, partly because it was fashionable at the time. We presented our research at this conference, which meant that we made up a poster about our results (which was slightly less informative than a brochure, but just as colorful). We presented it in a hall with all these other students and their posters while the viewing public meandered through. I stood around and answer questions, and largely tried to point people away from the fact that we never managed to actually grow any graphene. 

    I don’t have the poster on hand (I’ve got the files two broken computers ago), but I do have a couple images in my Ricochet library. 

    This was when we were trying to measure single atom thicknesses on an Atomic Force Microscope

    • #17
  18. Matt Balzer, Imperialist Claw Member
    Matt Balzer, Imperialist Claw
    @MattBalzer

    HankRhody Freelance Philosopher (View Comment):

    JustmeinAZ (View Comment):

    JosePluma, Local Man of Mystery (View Comment):
    As a result, you had to go looking for problems.

    Good grief. You had to go and remind me of Six Sigma (this was in the Aerospace industry) in which every single employee was required to participate. So everyone in a department had to identify a potential process improvement and write it up and get it signed off by every manager above you. A lot of crap came out of that.

    Yeah. This. Seeing a problem and fixing a problem helps everybody. Demanding that you see problems and fix problems on a set schedule means you have to make up problems, and that helps nobody.

    Really the Industrial Engineering types who ought to be handling lean manufacturing should know better. If you keep every machine in an assembly line running at full capacity all the time you’re going to create backlogs of partially completed work at various steps, which is a problem in a number of ways. This is a fundamental insight of the discipline; I wonder why it doesn’t get applied more often to people.

    Granted I could probably use some of that at my current job where we spend about an hour a day moving stuff around due to lack of warehouse space. 

    • #18
  19. TheRightNurse Member
    TheRightNurse
    @TheRightNurse

    navyjag (View Comment):
    God bless the nurses and ER folks at Norman, Oklahoma Regional Hospital.  Is there a fund we can donate to?

    No,  probably not.   However, answering the survey makes a difference.

    On a personal note,  I know that doctors and nurses particularly appreciate letters, cards, or even post cards.  We like hearing that our patients ended up okay and we really,  really appreciate the time it takes to physically write something and mail it.  We often post them in the break rooms and marvel at them. 

    • #19
  20. TBA Coolidge
    TBA
    @RobtGilsdorf

    HankRhody Freelance Philosopher (View Comment):

    JustmeinAZ (View Comment):

    JosePluma, Local Man of Mystery (View Comment):
    As a result, you had to go looking for problems.

    Good grief. You had to go and remind me of Six Sigma (this was in the Aerospace industry) in which every single employee was required to participate. So everyone in a department had to identify a potential process improvement and write it up and get it signed off by every manager above you. A lot of crap came out of that.

    Yeah. This. Seeing a problem and fixing a problem helps everybody. Demanding that you see problems and fix problems on a set schedule means you have to make up problems, and that helps nobody.

    Really the Industrial Engineering types who ought to be handling lean manufacturing should know better. If you keep every machine in an assembly line running at full capacity all the time you’re going to create backlogs of partially completed work at various steps, which is a problem in a number of ways. This is a fundamental insight of the discipline; I wonder why it doesn’t get applied more often to people.

    Because managers love saying, “I want 110%” because they think it sounds cool. Frankly, if everyone gave in the mid-80s things would probably work better than randomly galvanizing people. 

     

    • #20
  21. TheRightNurse Member
    TheRightNurse
    @TheRightNurse

    TBA (View Comment):

    It’s funny how ‘girl jobs’ tend to involve making posters, baking, and working after hours for free, and how this sort of thing goes on regardless of liberation and equality.

    I should point out that there is some amount of litigation surrounding this; hospitals are being advised to be sure to pay for the hours/supplies.  However, I can also say that it does not exactly happen that way.  One’s administrators often emphasize just how important it is to not be overtime since any incremental overtime affects everyone’s raise.  If we don’t meet our system-wide goals at the end of the year, then we will not have our raises funded.

    While they say that they want to ensure that everyone is paid fairly for the work they do, please report any off-site work done, etc, it is also very strongly and very clearly implied that doing so is detrimental to yourself and others.  If people weren’t to get their raises, it would be very clear why that would be (implying that it is clearly one’s personal responsibility to ensure timeliness in all regards, including project work).  Legal counsel makes it very clear that they cannot ever tell people to clock in on time but to continue charting or to deny themselves reimbursement for poster costs, but it is also very clear that one is meant to do it, but not complain.

    Again, I am lucky that I am not in this position as much as others are, but at other hospitals it isn’t just implied; it’s regularly and openly stated.

    There are many, many lawsuits floating around about this.  It is one of the many reasons why hospitals are so expensive.  Violating labor laws will eventually catch up with any organization unless there is some sort of enforcement.  Then we start veering into mafia territory.

    What is interesting is that many ‘girl jobs’ also tend to be flat rate of pay/salary.  This is to say that even with good annual reviews, there is no room for negotiation once hired.  There is no process of asking for a raise.  Teachers and nurses tend to be hired based upon a tenure track or an experience grid.  Once in place, there’s no real way to insist that your performance or education has entitled you to anything other than what the chart says.  There is no room for negotiation and the nursing managers do not have the authority, even if there were.

    • #21
  22. navyjag Coolidge
    navyjag
    @navyjag

    TheRightNurse (View Comment):

    navyjag (View Comment):
    God bless the nurses and ER folks at Norman, Oklahoma Regional Hospital. Is there a fund we can donate to?

    No, probably not. However, answering the survey makes a difference.

    On a personal note, I know that doctors and nurses particularly appreciate letters, cards, or even post cards. We like hearing that our patients ended up okay and we really, really appreciate the time it takes to physically write something and mail it. We often post them in the break rooms and marvel at them.

    Will do

    • #22
  23. Blondie Thatcher
    Blondie
    @Blondie

    Percival (View Comment):

    Posters? For crying out loud, I haven’t made a poster since junior high, and I was pretty salty about it then, too.

     

    This is why I never did the ladder, either. I said if I wanted to make posters  and bulletin boards for work I’d have become a school teacher. 

    • #23