Enhancing Expertise in the Cath Lab: The Positive Impact of the Clinical Ladder

Due to shifting practice trends and the financial uncertainly of the future of healthcare, now is an excellent time to strategically focus on the clinical staff in the cath lab – both registered nurses (RNs), and cardiovascular and radiologic technologists. A stable and knowledgeable cardiac catheterization laboratory team results in attention to customer satisfaction and quality outcomes, while a lack of staff can lead to shortfalls in these areas – something no hospital can afford amid the scrutiny of today. 

It is important to create a cath lab work environment that promotes recruitment and encourages retention of valuable staff. Corazon experience has shown that programs that integrate novice staff within an inclusive learning environment, while encouraging the competent and expert staff to enhance their clinical and leadership skills, are the most successful with staff recruitment and retention. 

Clinical ladders were first developed during the nursing shortage of the 1980s as adjuncts for recruitment and retention. They have been used in nursing departments for decades, and have been fully embraced by professional organizations such as the American Association of Critical Care Nurses (AACN).¹ Essentially, a clinical ladder offers a structured system that clearly lays out a path for staff career advancement (and economic rewards) while outlining skills required in the clinical setting for direct patient care. 

Clinical ladders exist in many forms, though most have multiple ‘rungs’ or steps based on how overall clinical functioning of the individual is defined within the context of the organization. A quick review of Cath Lab Digest’s monthly “Cath Lab Spotlight” feature revealed that labs with active clinical ladder programs elsewhere in the hospital appeared more likely to adapt a version for the cath lab. In fact, a majority of cath labs indicated that they were “in the process” of investigating a clinical ladder. A few labs also noted that a cath lab RN-specific clinical ladder was available in their department. 

Table 1 represents Dr. Patricia Benner’s concept that expert clinicians develop skills and understanding of patient care over time through a sound educational base, as well as a multitude of on-the-job experiences.² A clinical ladder can be built with set expectations around those levels of clinical development, and the steps can be either collapsed or expanded in regards to the expectations set forth by the hospital or departmental leadership.

Although the cath lab RN and technologist each bring unique expertise from their respective educational preparation, Corazon recommends cross-training as much as possible, as well as establishing work roles as a team, rather than isolated responsiblities. Cardiovascular Credentialing International (a not-for-profit independent credentialing agency) realized the importance of certification for both roles based on the standard body of knowledge related to the pre-, intra-, and post-procedural care of the patient. In response, the registered cardiovascular invasive specialist (RCIS) credential was created, and has emerged as a standard requirement (within 1-2 years of hire) in many cath labs, especially for labs hiring staff with minimal cath lab experience or those who are inexperienced with procedures, but have emergency department or critical care skills. Obtaining the RCIS credential will no doubt improve staff skills and knowledge base, and Corazon advises clients to consider this certification for staff as a means to ensure clinical and operation best-practice care standards are met. 

Of course, as the staff member progresses through the levels of the clinical ladder, expectations in all categories should increase. The detail criteria within each of the levels should be decided by a multidisciplinary cath lab team in an effort to raise expectations in a step-wise fashion. While the novice, along with the expert, should be proficient in all required competencies of their current level, they may not be cross-trained in all roles, initially only focusing on mastering their primary role. Corazon recommends the inclusion of multiple categories in a clinical ladder that will focus on developing the staff’s clinical expertise, proficiency in decision-making, communication skills, teamwork abilities, and leadership potential. Two categories to point out in particular are the quality improvement focus and staff leadership goal and project.

Quality improvement projects often arise from a review of cath lab outcomes, as assessed through participation in the American College of Cardiology’s National Cardiovascular Data Registry (ACC-NCDR). The NCDR requires the involvement of all knowledgeable cath lab staff in order to efficiently and accurately reflect patients’ clinical acuity in relation to their post-treatment outcomes. Staff should also be knowledgeable in reporting and then using cath lab data to drive improvements in care processes. 

The goal of the leadership project is to find an ongoing endeavor and become an expert in that subject matter. A staff member who is drawn to technology may choose to update the Impella left ventricular assist device (Abiomed) policy and competency, and then educate staff on this device. Over time, the staff member can become the lab’s liaison to the vendor. They can educate staff as advances in the technology occur, also serving as a resource for staff in complex situations. As the goal is accomplished, the employee gains greater experience and expertise in an area of interest. This is just one example of a scenario that could result in a win-win for the employee and the hospital or program.

Successful clinical ladders offer an opportunity for professional development, increased recognition, and financial rewards. Not only do staff prosper in this type of encouraging environment, but the hospital enjoys a high retention rate and the patients experience quality care. A highly functioning staff that is both motivated and satisfied with their work translates into better patient care and happier patients.  

References

1. Standards for establishing and sustaining healthy work environments. A journey to excellence, 2nd edition. 2016. American Association of Critical Care Nurses. Available online at https://www.aacn.org/wd/hwe/docs/hwestandards.pdf. Accessed August 25, 2016.
2. Benner P. From novice to expert : excellence and power in clinical nursing practice. Addison-Wesley Pub Co., Nursing Division, Menlo, Calif.: 1984. 

Katherine Kay Brown is a Vice President at Corazon, Inc., offering strategic program development for the heart, vascular, neuro, and orthopedic specialties. Corazon provides a full continuum of consulting, software solution, recruitment, and interim management services for hospitals, health systems, and practices of all sizes across the country and in Canada. To learn more, visit www.corazoninc.com or call (412) 364-8200. To reach the author, email kbrown@corazoninc.com.