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The forgotten rung: A clinical ladder for UAP

Gent, Patricia Lambert MS, BSN, RN, CCRN; Proulx, Joseph R. EdD, MSN, RN; Seidl, Kristin PhD, RN

doi: 10.1097/01.NUMA.0000442636.78453.2f
Feature: Specialty Focus: Magnet® hospitals: Magnet® Excellence

Despite job growth for assistive personnel and their distinction as part of the nursing workforce,there's a lack of momentum in all institutions, including Magnet facilities, for their development.

At the University of Maryland Medical Center in Baltimore, Md., Patricia Lambert Gent is a senior clinical nurse II and Kristin Seidl is the director of quality and patient safety officer. Joseph R. Proulx is a professor at the University of Maryland School of Nursing in Baltimore, Md.

The authors have disclosed that they have no financial relationships related to this article.



The Magnet Recognition Program® focuses on four components of nursing practice that not only attract and retain nurses, but also include standards for quality patient outcomes. Hospitals strive to attain Magnet® recognition and often use it as a framework for organizational nursing care by implementing structures and processes that support transformational leadership; structural empowerment; exemplary professional practice; and new knowledge, innovation, and improvements.1 Shared governance is the accountability and decision making of those within an organization to improve the services provided; it's an integral part of nursing at Magnet organizations. The organizational structure as a component of structural empowerment indicates that all levels of nursing should be involved in a shared decision-making process. Interdisciplinary relationships are also a component of exemplary professional practice and indicate collaboration with multiple disciplines.2 Integrating a shared governance model enables nursing staff to implement and realize the Magnet components and achieve high-quality outcomes.

The shared governance model—a cornerstone for Magnet institutions—isn't a participatory style but rather accountability-based leadership.3 With a shared governance model, structural accountability is based on components such that the professional nurse is responsible for the nursing care provided, as well as operational components of nursing services. The operational components are ensured within the clinical practice framework through the organization's internal structure.3 This means that nursing doesn't just focus on the care of one patient; it encompasses the whole process, which includes unit- and hospital-based operations, as well as staff members providing any aspect of those services. Unlicensed assistive personnel (UAP) provide many aspects of nursing care and are a part of service line operations. Nurses are therefore responsible for ensuring that the nursing care provided by UAP meets the standards of structural accountability.

Although requirements vary by state, most UAP who work in a hospital setting become certified nursing assistants (CNAs) in the state in which they work.4 However, UAP function at many different levels and take on many technical skills depending on their experience and care delivery area. Some common role titles for UAP include nurse extender, patient care partner, multi-skilled worker, patient-care aide, and technician.5 UAP provide direct patient care and assist in meeting the standards of care provided to patients. Their duties range from taking vital signs and assisting patients with activities of daily living to assisting with procedures and setting up equipment. UAP provide some aspects of nursing care and communicate their experience and observations to the nurse. This information is then incorporated by the healthcare team to deliver high-quality patient care.5

Currently, there are limited advancement opportunities for UAP. In 2008, UAP held about 1.5 million jobs, 29% of which were in the hospital setting, and by 2020, the job growth for UAP is expected to be 20%. This is mostly due to the growth of the elderly population; however, the increase in demand for healthcare service will also increase opportunities in hospitals.4 Despite job growth for UAP and their distinction as part of the nursing workforce, there has been a lack of momentum in all institutions, including Magnet institutions, for their development.

The authoritative style of management that once predominant in hospitals has since transitioned to a relationship-based leadership style that's prevalent in Magnet institutions. Behaviors of organizational leaders that show support for staff include being approachable and safe, caring, promoting teamwork, leading by example, resolving conflict constructively, confidence, and providing appropriate feedback.6 These behaviors impact all employees, not just RNs. With the role of the UAP in the hospital setting expanding, it might be in the best interest of organizations to include this role in the shared governance model. If institutions implement a shared governance model, they're putting into practice attributes such as accountability, empowerment, decision making, and collaboration, which should be extended to all of those on the patient care team.7 We review the evidence for and opinions of nurse leaders across the country regarding a clinical ladder for UAP within the context of the shared governance model.

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What does the literature say?

To evaluate the literature available on the history and current use of the UAP role in nursing care delivery, we performed a search of the CINAHL and MEDLINE database using the terms “unlicensed assistive personnel” and “UAP.” When using the search term “unlicensed assistive personnel,” 281 peer-reviewed articles were found, with 195 since 1992. Articles that examined the impact of UAP on patient outcomes were evaluated; this included six review articles.7–12 The literature focuses on the change of culture with the addition of UAP, the financial impact, legal issues, controversy over the UAP role, and nurse delegation and supervision of UAP. Based on the literature, it appears that the increasing use of UAP was based on the economics surrounding the nursing shortage and not outcomes-based research.5

One study reviewed 16 articles that focused on the impact of UAP on patient satisfaction.7 The definitions of the UAP role, as well as the instruments used to measure patient satisfaction, were inconsistent between the research studies. The results were split between an increase and no change in patient satisfaction scores; however, the nurses' lack of delegation skills was prevalent in five of the studies reviewed.7

Another study focused on a review of articles with data on nurse satisfaction, quality of care, productivity, and patient satisfaction to evaluate the care provided by the integration of UAP.8 The studies that were reviewed had many limitations, such as a small sample size, single-site studies, anecdotal studies, no comparison group, and questionable validity and reliability of the tools used to assess nursing outcomes. It was noted that nurses aren't prepared to delegate to UAP, and that UAP integration can contribute to personnel issues. It was also concluded that an evaluation method should be conducted to define the impact that UAP are having on care quality, patient satisfaction, and cost.8

One review of 20 research articles about UAP utilization used theoretical perspectives to discuss the need to employ UAP.9 These perspectives help develop how the nursing profession defines the impact of nursing practice in relation to patient care. The use of UAP was evaluated, along with their threat to RNs and impact on cost effectiveness and care quality. Results were inconsistent due to the use of unvalidated surveys to evaluate the effectiveness of UAP, as well as inconsistent results concerning the cost effectiveness of implementing UAP.9 Despite the overlap of articles used in some of the reviews, they all concluded that there's lack of data to support the integration of UAP based on cost effectiveness, patient satisfaction, and care quality.

Most recently, a qualitative study conducted at three sites (one academic medical center and two community hospitals) reported that the barriers to teamwork in the RN-UAP relationship include a lack of clarity of the UAP role, lack of team effort demonstrated by not involving the UAP in decision making, poor conflict resolution, deficient delegation by numerous RNs, and “it's not my job” syndrome.11 The implications of this study demonstrated that the RN-UAP relationship does impact patient care and that these issues need to be addressed on a unit level by engaging staff, focusing on teamwork, and changing the UAP model of care.11

Another study demonstrated the impact that UAP had on maintaining Magnet institutions' pressure ulcer rates below the national benchmark.12 This was accomplished by empowering and educating the UAP about their role in pressure ulcer prevention. Despite the barriers presented in the RN-UAP relationship and their impact on quality and safety, the author described how role clarification, teamwork, and involving UAP can have a positive effect on patient outcomes.12 Addressing the barriers on a unit level by engaging UAP can improve safety and care quality.

Research shows that UAP do influence the delivery of patient care and impact patient outcomes, although there's no data to support the true effect. Therefore, it would be prudent to start engaging UAP to work to the full capacity of their role. This should be done not to replace RNs, but rather to enhance high-quality patient care. Data should also be collected to evaluate how UAP influence patient outcomes.

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What do the experts think?

The concept of developing a career ladder for UAP was discussed with three nurse leaders across the nation. The concepts of teamwork, shared governance, employee commitment, and financial feasibility were discussed. The director of professional practice and patient- and family-centered care at an academic hospital in the Pacific Northwest believes that integrating UAP on the unit level would be beneficial because, “we're working as a team, so any decisions we make about nursing practice have impact on the UAP. Anything we can build together has a much greater chance of being sustained over time.”13

The director of perioperative services at an academic hospital in the mid-Atlantic region concurs that the integration of UAP into the shared governance model is instrumental to having UAP feel like they're a part of the team.14 Commitment versus adherence was prevalent in the conversation.15 Adherence to the structural policies of an organization can be very difficult to attain. Preparation in developing a committed employee with a shared vision will help the organization reach the desired goals faster. This director has implemented a two-tiered ladder on one of her units and created a senior technician position. The senior techs are positioned at another pay grade and have additional responsibilities, including involvement on various unit- and hospital-based nursing committees.14

The assistant vice president of patient care services at a teaching hospital in the mid-Atlantic explained that, in his particular facility, UAP are included on organizational committees and even act as cochairpersons. In this organization, the involvement of UAP is considered a continuous part of the Magnet journey.16

Despite the favorable concept of a career ladder, and modified versions currently being implemented, there's no agreement about the financial feasibility of integration. One of the hospital directors explained that currently there are three roles with three separate pay grades for UAP. This consists of patient care assistant (PCA), critical care technician, and even a program for those PCAs who are in nursing school, which includes the opportunity to be mentored by an RN while working as a PCA. It would be difficult to implement a formal career ladder into this system, but theoretically possible despite the current economic climate. Different levels would have to be added with an increasing pay scale all under the same umbrella.16 However, the director of professional practice doesn't think that it's financially feasible to include UAP in a career ladder given the current economic climate, but concurs that it should culminate with entry into a nursing program.14

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Is it right for your facility?

A career ladder for UAP may be beneficial for recognizing their contribution not only to patient care, but also to the organization and their own personal advancement. The shared governance model is the basis for Magnet institutions and focuses on nurse satisfaction and nurse-sensitive patient outcomes such as restraint use, pediatric I.V. infiltrates, fall rates, pressure ulcer rates, and healthcare-associated infection rates. The outcome data related to all of these indicators can be influenced by UAP. When focusing on patient satisfaction, the questions that are specific to nursing care focus on courtesy and respect, careful listening, and response time, which can also be influenced by UAP interaction with both patients and visitors.17

There's some literature to support that as many as 28% of patients were unable to identify whether their caregiver was an UAP or a nurse.18 With the UAP title unstandardized throughout the United States, consumers may not be aware of the UAP role in the hospital.13 Patient satisfaction is obviously affected by UAP and without patients being able to make a distinction between the UAP and the nurse, nurses should embrace UAP and the impact they may have on nursing quality indicators.

Nurse satisfaction can also be improved when there are positive relationships between nurses and UAP. The nurse collaborates with UAP frequently throughout the shift, and this interface could affect nurse satisfaction in the work environment. It may be time for nursing leadership to engage a large group of employees who haven't previously been recognized for their impact on patient care.

In order for every institution to determine if a career ladder for UAPs is advantageous, a cost-benefit analysis should be conducted. The costs that must be considered in the implementation of a career ladder are the increase in financial compensation as UAP progress and the educational benefits provided. The role of UAP in a hospital system functions in many different capacities. Some UAP perform the basic functions of a CNA, whereas others assist physicians with procedures.

UAP are entering into the hospital system with previous medical experience as paramedics, emergency medical technicians, and military corpsmen.14 This experience is being utilized on intrahospital transport and rapid response teams.14 The career ladder could include those who want to become nurses, as well as those who want to be career UAP, taking into account the different performance levels and backgrounds. Training models would also have to be conducted to educate not only staff, but also management on the career ladder progression, as well as portfolio development and RN-UAP communication classes.

The benefits of a career ladder may help reduce staff turnover and increase retention. The impact of the ladder may affect nurse satisfaction and may also help retain those UAP who aspire to become nurses. Employees are most effective when they're committed to an organization and not just adherent to policies and procedures. Commitment is affected by work experience (socializing force) with peers and organizational leaders. Attitude toward the organization, the trust and dependability of the organization, and the perception of an employee's importance to the organization all influence commitment to the organization.15,16 The implementation of a career ladder may engage UAP in the organization to progress successfully through the system. UAP who don't desire to become nurses may also be more likely to be retained in the organization, which may become increasingly important given the nursing shortage.

As previously discussed, the impact of UAP on patient safety and quality outcomes needs to be assessed and taken into consideration. Nurse-driven cost improvement projects (allocation or reallocation of unit resources, the use of data to guide budget formulation, implementation, and monitoring) reflect cost savings of $5,000 to $20,000 and market return on investments from RN publications and research.19 Overall, with a cost saving average of about $2.3 million, the argument can be made that there would be an increase in savings when engaging UAP participation.19

Being a Magnet facility and practicing within a shared governance model includes being accountable to the activities of UAP who are part of the healthcare team and influence patient safety and care quality. Magnet facilities realize a positive return on investment by engaging RNs; another positive return may be seen by engaging and integrating UAP completely into the organizational system.

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Empowerment for all

The implementation of a career ladder for UAP is a decision that each Magnet and non-Magnet organization should consider. Engaging UAP on a unit and organizational level can have a positive effect on patient safety and quality, as well as nurse and patient satisfaction. More research needs to be done on the RN-UAP relationship and UAP effect on care quality. Despite the lack of research data on UAP contributions to patient care, it can be hypothesized that engaging these members of the healthcare team will benefit patient care, as well as healthcare organizations. Allowing UAP to be accountable for their participation in patient care and empowering them by valuing their contribution can improve collaboration between team members.

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