THE RELATIONSHIP BETWEEN CAREER LADDER AND NURSES JOB SATISFACTION AT A HOSPITAL

Background: Career ladder is given to nurses to encourage and maintain professional development and practice of nursing. Career ladder has an impact on raising clinical levels, promotion opportunities, competency complexity, rewards and recognition. In this study, the career ladder has started by mapping and conducting, credentials and competency assessment at the levels of pre Nurse Clinicians, Nurse Clinicians Level I and Nurse Clinicians Level II. Almost half of the nurses were dissatisfied (47.2%) with their career development. Aims: This study was to analyzed the relationship between the career ladder and nurses’ job satisfaction. Methods: This study was a quantitative correlational study with a cross-sectional approach. There were 108 nurses as samples selected using consecutive sampling techniques. These respondent who met the inclusion criteria came from Inpatient Room, (i.e VVIP, VIP, Class I, Class 2/3, Ophthalmology Inpatient), Polyclinic, Chemotherapy Unit, NICU (Neonatal Intensive Care Unit), ICU (Intensive Care Unit), Hemodialysis, Emergency room and COT (Centra Operation Theater). Data were analyzed using the Spearman test. Results: There was a significant relationship between career ladder (p=0.000) and nurse’ job satisfaction. The nurse were satisfied with her career development related to implementation of career ladder. Besides, career ladder allowed to be promoted as the heads of the rooms. Rewards and recognition of nurses’ competencies through job promotion affected nurses’ satisfaction. Conclusion: Career ladder affects nurse satisfaction. Nurses can advance their careers through a career promotion, competencies, rewards and recognition from other health professionals. Support from nurse manager is needed as a form of mentoring and evaluation of nurse performance in the career ladder.


INTRODUCTION
Nursing takes an important role in providing health services to patient and community. Nurses provide professional nursing services to individuals and the community and keep being evaluated for the quality and security guarantees (Potter and Perry, 2009).
Nurses perform services to patients for 24 hours assigned per shift. The number of nurses at hospitals is the largest and thus affects the quality of nursing services. Therefore, nurses are expected to provide excellent professional skills to improve the quality of nursing services. Efforts to develop competence and professionalism as well as give appreciation to nurses could be done through career development.
Career development is a personal improvement to achieve a career plan and work plan according to the level in an organization (Ardana, Mujiati and Utama, 2012). Nursing career development systems have been developed and implemented in various countries such as the United States, Norway, China, Thailand, Japan, and others countries. Career development, therefore, can be carried out through a career ladder.
Career ladder is a system to improve performance and professionalism, in the work field through increased competence (Indonesian Ministry of Health, 2013). Career ladder offers the opportunity to pursue certain clinical, educational, research, or managerial-focused pathways and to measure nurses' achievement (Kelly, 2010). The clinical level encourages and maintains professional development and practices of nursing, for example, family care (family-centered care), patient advocacy, patient and family education, assessment skills, critical thinking and understanding of the health care system (Burket et al., 2010). Benner (1982) stated that a career ladder model illustrates five levels of skill development including novice, advance beginner, competent, professional, and expert. The implementation of such the model in Indonesia and other countries uses Benner's theory development to the level of researchers. The career ladder consists of clinical nurses, nurse managers, educator nurses and research nurses. Career ladder provide benefits in career development, promotion systems, competency complexity, rewards and recognition (Benner, 1982;Swansburg and Swansburg, 2000).
Career development is career planning and actualization as a critical life process that involves individuals and employees (Marquis and Huston, 2010). Career development is a significant opportunity for professional and educational development in an organization (Cowden and Cummings, 2012). Career ladder in nursing jobs provides opportunities to improve quality and competence through formal and nonformal training and education. Professional behavior such as education, leadership and team's morale will increase through career ladder since, promotional opportunities affect nurse' satisfaction of nurses (Zehler et al., 2015;Lu, While and Louise Barriball, 2005). Promotion could uplift nurses' careers in terms of management, education or research. To have promotional opportunities professional nurses could experience professional career ladder (Swansburg and Swansburg, 2000).
The complexity of competencies becomes a challenge for nurses. Nurses have responsibilities to provide nursing care according to their competency based on the career level (Benner, 1982). Increasing nurses' competence through career ladder allows for continous professional development. Continous professional development is a process undertaken to maintain and renew the development of health services through high standards of professional practice (Indonesian Ministry of Health, 2013). On the other hand, rewards and recognition are the benefits of career ladder. Nurses in career ladder will receive recognition and rewards through higher salary and career mobility that show expertise, management and teaching skills (Pullen, 2017 A previous study found nurses also showed satisfaction at work because they could gain personal and professional development and opportunities for career advancement through career ladder (Bjørk, Hansen, et al., 2007). In other the words, career ladder system for advancing career has an impact on nurse' job satisfaction. Nurses with a higher career level will be more satisfied than nurses with a low career level (Riley et al., 2009;Bitanga and Austria, 2013 Hospital, 2015). This previous study suggested that nurses were quite satisfied with the career ladder applied. Besides career advancement, it is necessary to improve skills through career ladder.
Efforts to improve career as a job satisfaction factor cause nurses to leave their jobs. This situation is, known as turnover. Research by Bjørk et al. (2007) found nurses who can uplift their career level would want to continue working at hospitals. Similarly, Chae et al. (2015) found the career ladder system could result in low desire to leave the hospital. Besides that, several of nurses are still young and have not been entitled as civil servants/PNS. The temporary contract, could force nurses to develop their career at other hospitals. The number of nurses turnover in 2015 was 3 people and increased by 13 people in 2016 (Human Resource of Hasanuddin University Hospital, 2016). This becomes concern for the Hospital to apply a career ladder system.
Nurses' career ladder is expected was supposed to develop nurses' careers and provide them incentive/remuneration in addition to apart from monthly salary given to nurses as a form of an appreciation and recognition. The preliminary data obtained suggested that some of nurses were quite satisfied with their career development although there is a need for clear career advancement and its impact on nurse satisfaction It became the basis for researchers to carry out research about the career ladder that affect job satisfaction of nurses this study aimed to identify the relationship between the career ladder and nurses' job satisfaction.

METHOD
The design of this study was correlational quantitative, aiming to examine the relationship between two or many variables in one group (Grove, Gray and Burns, 2015). This study used a cross-sectional approach to assess the relationship between the career ladder and nurses' job satisfaction.
The number of respondents was determined by 10% of accuracy value, and the determination of sample size was calculated using the Isac & Michael table 188 population with a value of α (0.01). As many as 108 people as sample was obtained by using consecutive sampling in which all participating subjects with inclusion criteria were included until the required number was fulfilled (Sastroasmoro and Ismael, 2010). These respondents were nurses who worked in Inpatient Room (i.e VVIP, VIP, Class I, Class 2 & 3, Ophthalmology Inpatient), Polyclinic, Chemotherapy, NICU (Neonatal Intensive Care Unit), ICU (Intensive Care Unit), Haemodialysis, Emergency room and COT (Central Operation Theatre). The respondents fulfilled the inclusion criteria, i.e., willing to participate in the study and undergoing pre-nurse clinician level to Nurse Clinician Level II.
The research instrument used was questionnaires about career ladder and job satisfaction. As for the career ladder questionnaire, this study adopted the instruments used by Suroso (2011). The questionnaire is comprised of respondent's characteristics which are age, gender, marital status, education (bachelor's, master's and doctorate's degrees), period of work, and level of clinical career ladder. This study defines career ladder as a system for advancing a nursing career by levels aimed to promote and develop career through promotion system, competence, rewards and recognition. The career levels vary from pre nurse clinicians who just graduated from both bachelors of nursing and masters of nursing and had no work experience; nurse clinicians at level I are nurses who graduated from bachelors of nursing or maters of nursing and had 2year work experience and had passed a clinical authority test. In addition to that, nurse clinicians at level II are those who graduated from bachelors of nursing or masters of nursing and had 3-5 years of work experience, as well as had passed a clinical authority test.
Career development refers to career planning and management efforts, especially the nurse leader to organize career promotion for nurse clinicians. A promotion system in the career ladder provides nurses with an opportunity to upgrade their position to be clinicians, managers, educators, and researchers. Competence refers to the complexity of nurse's authority based on the career levels. Rewards in the career ladder are the act of giving incentives to nurses according to their career levels. Career ladder provides recognition of authority as well as improves competence and opportunities for nurses to make decisions in nursing care based on the career levels. Career ladder as an independent variable was measured using Likert scales which are Strongly Agree, Agree, Disagree and Strongly Disagree. While job satisfaction became a dependent variable that can describe nurses' attitudes towards work situations and work behavior to obtain equal rewards and welfare. Job satisfaction was also measured using the  (Dahlan, 2014). Bivariate test was in use to assess the relationship between the independent variable (career ladder) and the dependent variable (nurses' job satisfaction). If a pvalue is < 0.01, it means there is a relationship between the independent variable and the dependent variable.
This research has obtained the ethical clearance from the Ethics Committee of the Faculty of Medicine, Hasanuddin University with ethics number of 336/H4.8.4.5.31/PP36-KOMETIK/2017. Based on the common research ethics, before getting the respondents' consent, research objectives were explained first to the respondents. After that, informed consent sheets were distributed when the respondents agreed the research participation procedures. The respondents signed the informed consent forms and then were given questionnaires to be filled in. To maintain the confidentiality of respondents, initials of respondents' name were used.

RESULTS AND DISCUSSION
In this part, the results of the relationship between career ladder and nurses' job satisfaction were further explained. Table 1 shows the demographic distribution of nurses. Most of the nurses are female (78.7%). As many as 74.1% of bachelors of nursing. Most of the nurses (55.6%) were at the Nurse Clinician Level I. The average age of the respondents was 28 years, and the average period of work as 2 to 7 years.  Table 2 shows the variable career ladder had a p-value of = 0.000. It means there was a significant relationship (pvalue < 0.01) between career ladder and nurses' job satisfaction with the strength of the relationship is positive. The career ladder aimed to advance nursing career in stages by fulfilling the requirements such as level of education and period of work and to develop nursing professionalism (Indonesian Ministry of Health, 2013). Career development supports excellent nursing performance by rewarding nurse clinicians who can fulfill the requirements (Adeniran, Bhattacharya and Adeniran, 2012). Besides, it also concerns about professional development (Chen et al., 2010). Nurse leaders used career ladder system in facilitating the development of nursing professionals (TØrstad and BjØrk, 2007). In this case, they act as facilitators that develop evidence-based knowledge and skills. Professional clinical nursing development becomes a way to provide high quality of nursing services. Professional development is expected to embed critical thinking skills and increase nurses' job satisfaction (Winslow et al., 2011). In regards to increase nurses' job satisfaction, the career ladder system can be the option.
Along with the development of science and technology in which patients' needs and request might vary, nurses need to improve and renew their competencies, and thus career ladder contributes to professional development (Hariyati and Safril, 2018). For improving nurses' clinical competence based on the career levels, hospital management provides Pre Nurse Clinicians Level a-year internship. After that, they submit an application for competency assessment as Nurse Clinicians Level I.
The hospital management could develop nurses' professionalism based on the clinical levels (Shermont, Krepcio and Murphy, 2009). The Nurse Clinicians Level I will receive different training program program from Nurse Clinicians Level II for different clinical authority, roles and responsibilities of each clinic level. Moreover, training programs which could be formal and educational programs on intensive care, haemodialysis and chemotherapy depend on the clinical authority in the practice areas.
Most of the nurses stated that the implementation of career ladder went well because nurses had high opportunities to increase their professionalism. What goes beyond this situation was that nurses understood the importance of professional development to improve competence. In this case, the career path is known as continous professional development (Hariyati et al., 2017). Similarly, hospital management facilitated competency improvement programs, such as formal education, training and seminars.
Nurses' satisfaction with career ladder was indicated from nurses' interactive capability with colleagues and others in the organization as a major factor of career advancement (Sheikhi et al., 2016). Nurses also had satisfaction when interacting with colleagues and the head of the room who always provided direction and guidance that make work easy and enjoyable. Nurses can improve their competence through mentoring as part of career ladder activities.
Nursing leadership dedication to implement consistent career ladder not only enriches nurse's productivity, but also reduces absenteeism and employee turnover (Moore, Meucci and McGrath, 2019). Therefore, the management especially nursing management supports the implementation of career ladder to increase nurses' productivity and reduce turnover.
A career ladder program also gives nurses the opportunity to reach the position of being a nurse manager, nurse educator and nurse researcher from the clinical level pathway as a promotion system. Ko and Yu (2014) stated that career ladder can improve the position of nurses by increasing their status in the leadership and management system. It has a significant function for succeeding to achieve pathways to nursing leadership positions (Drenkard and Swartwout, 2005). Opportunities to get promotion can increase employees' job satisfaction too (Suroso, 2011;Lorber and Savič, 2012). This is the reason why the nurses' job satisfaction with career ladder was quite high because promotion opportunities for nurses were wide open through the career stages they followed and fulfilled their requirements.
The promotion system in career ladder begins from Nurse Clinicians Level II. The Nurse Clinicians Level II can be promoted to be Nurse Managers Level I respectively if fulfilling the requirements. The Nurse Managers Level I reaches to Nurse Managers Level II will be promoted as Nurse Managers Level II if fulfilling the requirements. The Nurse Clinicians Level III will be promoted as Nurse Educators Level I if they have completed the requirements. Nurse clinicians who want to become nurse researchers must pass Nurse Clinicians Level V (Swansburg and Swansburg, 2000;Indonesian Ministry of Health, 2006). Shermont, Krepcio and Murphy (2009) stated that career ladder programs benefit nurses to increase clinical levels and positions in leadership as nurse managers.
Hospital management, especially nursing management, need to to promote the career development at Nurse Manager Level I to Level V. The Nurse Clinicians Level II can also occupies the position of head of the room (nurse manager) and is placed in the management section.
Most of the nurses felt satisfied because career ladder provides equal opportunities in promoting the job positions if they fulfilled the requirements. Equality through career promotion can enhance nurses' skills and talents, as well as in turn the efficacy, effectiveness and quality of care (Kumar, 2016). Therefore, professional empowerment is very important to support the career development.
The development of career level depends on nurses' work experience. The average nurses' work period was 2-7 years, and thus the opportunity to develop the career level was quite large. Nurses who have worked for 3 years and above with professional nursing education registered and fulfilled the requirements can be promoted to Nurse Clinicians Level II as long as they have a high level of competence. It indicated that nurses with clinical experience of 2 years or less showed a low level of nursing competency (Kim and Kim, 2015).
Nurses who have clinical experience of 2 years and below are pre-Nurse Clinicians as or beginner nurses who and must have to pass an a-year internship. For 1 year who will After carrying out nursing practices based on clinical authority in the internship, they will to be assessed later as CN Nurse Clinicians Level I (Indonesian Ministry of Health, 2013). The Nurse Clinicians Level II who have worked for 3 years and more can be promoted to nurse managers. In other words, experience is the key to career advancement, management improvement, and mastery in clinical skills (Sheikhi et al., 2016). Adeniran et al. (2013) revealed that promotion in formal career ladder offers additional incentives in salary increase and seniority. In other words, seniority is also a factor affecting promotion in the career ladder program. The longer a nurse works, the higher the nurse's clinical level is. Likewise, increased incentives is the reason for reducing the number of nurse turnovers. Lack of opportunities for promotion may cause nurses leave It is concluded that career ladder affects nurses' desire to keep working at their institutions.
Similarly, Liu et al. (2012) explained that the implementation of career ladder is related to not only salary but also job satisfaction to retain nurses. Nurses' competence becomes a challenge in providing nursing care. Bjørk et al., (2007) found nurses showed an increase in competence and applied skills when there is a career development. The performance characteristics of nurses at different levels were seen in skills acquired by nurses (Benner, 1982). Increasing competence for providing a good quality of nursing services through career ladder allows nurses to obtain opportunities for ongoing professional development. Therefore, an increase in nursing knowledge and skills, as well as empowering capacity could improve the quality of patient care based on the best scientific evidence (Burket et al., 2010). Besides, continuous education and professional development programs support to enhance individual abilities based on the clinical nursing authority (Oyetunde and Oluwafunke, 2015).
Research by Weng et al., (2015) discovered that there were significant With increased competence in the career ladder systems, nurses can receive rewards and recognition from health professionals like physician, pharmacist, laboratory assistant, and the other and patients since they become providers of nursing care to clients (Benner, 1982). Rewards and recognition for the clinical level achieved indicate an increase in nurses' clinical skills and experience (Duffield et al., 2014). Rewards are given to nurses based on their clinical level responsibilities, experience and performance. The career ladder program is one of the approaches to reduce nurse turnover through recognition and appreciation (Allen, Fiorini and Dickey, 2010). Research by Kwak et al. (2010) also stated that career ladder becomes a recognition and appreciation for nurses' clinical expertise in providing patient care, and it can increase nurses' job satisfaction.
Rewards for increasing nurses' clinical level is performed by giving professional development programs to nurses. To improve the clinical level, nurses have to have higher education. For example, Nurse Clinicians Level I with bachelor's degree need to pursue graduate education. Hospital management has provided an opportunity for the nurses to pursue masters of nursing. This can be seen from some nurses who have a master's degree (see Table 1). According to Dill, Chuang and Morgan (2014), the hospital management's support is required to implement career ladder.
Rewards for improving nurses' career can be in the form of higher income/incentives (Swansburg and Swansburg, 2000). Nurses felt less satisfied with income/incentives since they thought that their roles were less properly valued (Masum et al., 2016). The results of this study indicated that there was a significant relationship between rewards and job satisfaction (p-value = 0.00) (see Table 2). The increase in income/ incentives follows the nurse' clinical levels. In other words, Nurse Clinicians Level I will get different income/incentives from Nurse Clinicians Level II. Meanwhile, Nurse Clinicians Level I and II have different amounts of incentive from nurses working in the care rooms. This is due to the clinical authority in the specific practice areas which run particular treatments (Indonesian Ministry of Health, 2013). The Nurse Clinicians Level I and II in the chemotherapy, haemodialysis and intensive care rooms receive different incentives from Nurse Clinicians I and Nurse Clinicians in the treatment room. Such differences of incentives affect nurses' job satisfaction according to their areas of practice and clinical authority. Robbins and Judge (2013) revealed that recognition gives nurses chances to participate in the decision making process and authority and nurses' autonomy improvement. Fusilero et al., (2008) also revealed that decision making and professional autonomy were closely related to an increase in the career level of nurses. The Nurse Clinicians I and Nurse Clinicians II have the authority to provide nursing care to patients and get involved in decision making with critical thinking skills. However, it should be noted critical thinking skills of nurses are related to nurse competence. The Nurse Clinicians II will have critical thinking skills along with increasing competence. A study conducted by Chang et al. (2011) pointed out that nurses' critical thinking skills got better when nurses had high levels of education and enough work experience.
A career ladder program provides opportunities to gain knowledge and skills, and thus nurses' expertise can be collaborated with other professions' expertise (Korman and Eliades, 2010 However, there are still health professionals such as doctors who seem to have high status for their professions Research by Atefi et al., (2014) stated that doctors overlooked nurses' clinical skills. This is due to an unrealistic superiority between doctors and nurses who always rely on doctor's instructions. Therefore, a career ladder system can facilitate nurses to improve their clinical skills and provide nursing care properly in accordance with the clinical authority. In turn, other professionals can recognize their skills as well (Bjørk, Samdal, et al., 2007).

CONCLUSION
A good implementation of career ladder can encourage nurses to participate. Through career ladder, nurses can continue improving their career up to the highest level. Nurses work not only at the clinical level but also in the position of being a manager. The support of the heads of the rooms was required because the competency assessment could raise the nurses' clinical level. Speaking about education, higher education can accommodate nurses to have better competence. The amount of incentives given were in accordance with their clinical levels. There is recognition from other health professions as an impact of increasing skills through career ladder. Knowing that, the nurses felt satisfied with of the career ladder.
The hospital management support was also expected to concern about the nurses clinical skills and competencies through career ladder. They could provide professional development programs and increase nurses welfare since nurses play a important role and responsibility for providing professional nursing services. When nurses are valued for their roles, they will be satisfied with their work. In other words, such rewards can make nurses clinical skills and competencies stand out in front of other health professionals.
The career ladder is associated with the role and support from nurse managers as a mentor and assessor in improving nurse competencies. The clinical authority will belong to the nurses according to their clinical levels after they passed the performance assessment. Therefore, nurse managers need to update knowledge and insights through trainings, and thus they can be assessors and mentors for nurses' work in accordance with the clinical authority.

CONFLICT OF INTEREST
There is no conflict of interest in this study.