Step up: Help nurses climb the clinical ladder

Nurse Manager Website, February 5, 2006

By June Marshall, RN, MS,  senior director of clinical practice, research, and professional development, Children's Medical Center Dallas

Learning objectives: After reading this article, you will be able to
1. recognize the theoretical models used in clinical development programs and their characteristics
2. indicate why it's important to have a clinical ladder or advancement program

As organizations strive to create safe environments and improve patient outcomes, retaining experienced nurses is essential. Nurse leaders have developed many creative strategies to retain their best nurses with the aim of providing expert clinical care for patients and families.

One such strategy is the clinical ladder. Clinical ladders recognize and reward nurses for their professional development and expertise, while encouraging them to remain involved in direct patient care activities.

Benner's model
Several models can be used to create clinical ladder programs for nurses. One model, described by Patricia Benner, author of From Novice to Expert: Excellence and Power in Clinical Nursing Practice, addresses the following stages of clinical intuitive thinking, and clinical decision-making skills that nurses acquire as they develop professionally:

  • Novice level
  • Advanced beginner
  • Proficient
  • Competent
  • Expert

Benner's work was used as a theoretical framework for our initial clinical ladder at Children's Medical Center Dallas. The current ladder is being revised by our Professional Development Council, and Benner's work is part of the framework for our forthcoming Professional Advancement Program.
In our program, nurses interested in climbing the clinical ladder submit portfolios that include clinical exemplars; evidence of professional development in areas such as leadership, communication and collaboration, and research; and reference letters from colleagues. The candidates then appear before a panel of their peers to complete the promotion process.

The Synergy model
The American Association of Critical-Care Nurses' (AACN) Synergy model is also popular in professional development programs. Developed as a way for the critical care nursing practice to meet patient needs and improve outcomes, the core concept of the model is that the needs or characteristics of patients and families influence and drive the characteristics or competencies of nurses. According to the AACN, synergy results when the needs and characteristics of a patient, clinical unit, or system are matched with a nurse's competencies.

The model identifies eight patient needs or characteristics and eight nursing competencies. When these patient needs and nursing competencies are aligned, better outcomes occur. The eight patient characteristics evaluated by nurses are

  • resiliency-the capacity to return to a restorative level of functioning using compensatory/coping mechanisms
  • vulnerability-susceptibility to actual or potential stressors that may adversely affect patient outcomes
  • stability-the ability to maintain a steady-state equilibrium
  • complexity-the intricate entanglement of two or more systems (e.g., body, family, therapies)
  • resource availability-the extent of resources (e.g., technical, fiscal, personal, psychological, and social) the patient/family/community bring to the situation
  • participation in care-the extent to which the patient/family engages in aspects of care
  • participation in decision making-the extent to which the patient/family engages in decision-making
  • predictability-a characteristic that allows one to expect a certain course of events or course of illness

Nurses then use eight nursing competencies to respond to these patient needs to enhance outcomes. Within each competency, there are varying levels of expertise the nurse may exhibit, ranging from competent (1) to expert (5). These competencies include

  • clinical judgment
  • clinical inquiry
  • facilitator of learning
  • collaboration
  • systems thinking
  • advocacy and moral agency
  • caring practices
  • response to diversity

Combine and refine
Both Benner's and the Synergy model can stand alone or be combined with other models or ideas for professional development. For example, the Career Advancement Program at the St. Petersburg, FL-based All Children's Hospital combines Benner's model with the Synergy Model and establishes performance standards, behavioral characteristics, and measurable outcomes for four levels of practice from entry level through expert. The performance standards and behavioral characteristics focus on whether the nurse meets the patient's and family's needs, and the outcomes are evaluated through patient satisfaction, self-evaluation, and performance appraisal measures.

Benefits abound
Creating and supporting a clinical ladder or other advancement program for nurses has many benefits, one of which is associated with costs to the organization. Most clinical ladder programs have financial incentives associated with advancement, either through a raise in base pay or payment of a bonus awarded at the time of advancement. It is important to weigh these costs against the larger cost to the organization should it have to replace experienced nurses. An effective career development program encourages nurses to remain at an organization with which they feel valued and challenged professionally-meaning the cost savings and benefits of implementing an advancement program often outweigh the costs and risks associated with replacing experienced nurses.

A clinical ladder encourages managers to take accountability for turnover, vacancy rates, responsible financial management, and various of patient outcome metrics. It is also an important strategy for re-
taining experienced staff and ultimately improving patient outcomes.

If experienced nurses do not see opportunities for growth in an organization, they may be unwilling to stay with it. If a unit or department is constantly orienting new staff, meeting performance objectives becomes difficult. Clinical ladders are a useful tool for providing growth opportunities for experienced staff.

Implementing an advancement program can lead to improved nurse satisfaction, increased retention, reduced turnover, and can result in better patient outcomes. Clinical ladders play an important role in retaining the best nurses and facilitating their development as frontline leaders. 
Benner, P. (1984). From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley.

Curley, M.A.Q. (1998). Patient-nurse synergy. Optimiz-
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Czerwinski, S. et. al. (1999). The Synergy Model: Build-
ing a Clinical Advancement Program. Critical Care Nurse. Vol. 19, No. 4. August 1999.