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How to Create a Clinical Ladder To Improve Nurse Retention and Performance

A nursing clinical ladder program can help you retain, develop, and motivate your nursing staff. As a recognized and desirable advancement program, it can also provide a competitive advantage when recruiting new nurses for your healthcare organization. Here’s what you need to know to begin your clinical ladder initiative.

What is a clinical ladder?

A clinical ladder is a career development model that recognizes and rewards nurses for their clinical expertise, professional growth, and leadership skills. A clinical ladder program provides nurses with a clear and structured path to advance their practice, education, and achievement within their organization. It also provides a key opportunity for organizations to increase nurse engagement.

Clinical ladder programs typically consist of several levels, or tiers, that reflect increasing nurse competencies and responsibilities. Each level has specific criteria and expectations that nurses must meet to qualify and advance. For example, a clinical ladder program may require nurses to demonstrate clinical excellence, pursue continuing education, participate in quality improvement projects, mentor other nurses, or assume leadership roles.

Why implement a clinical ladder program?

A clinical ladder program in nursing can benefit both your organization and your staff. By implementing a clinical ladder program at your healthcare organization, your organization can:

  • Improve nurse retention and satisfaction by providing nurses with opportunities for career advancement, recognition, and rewards.
  • Enhance nurse performance and improve patient outcomes by fostering a culture of clinical excellence, evidence-based practice, and innovation.
  • Support nurse recruitment and retention by attracting and retaining highly skilled and motivated nurses who value professional development and growth.
  • Increase nurse engagement and empowerment by involving nurses in decision-making, problem-solving, and organizational change.
  • Reduce nurse turnover and burnout by creating a positive work environment, reducing stress, and improving morale.

a healthcare team celebrates a nurse’s promotion.

How to create a nursing clinical ladder

Creating a nursing clinical ladder program requires planning, collaboration, and evaluation. Here are some recommended steps to follow to design and implement a successful program:

1 – Appoint leaders

Establish a steering committee that includes representatives from nursing administration, nursing education, nursing practice, and frontline nurses. The committee will be responsible for developing the vision, goals, and framework of your program.

2 – Assess needs

Conduct a needs assessment and a literature review to identify the current and future needs of your organization and your nursing staff, as well as best practices and evidence from programs from other organizations.

3 – Define levels

Define the levels, including criteria, and expectations, of your program. Levels should reflect the different stages of nursing practice, from novice to expert. The criteria should be clear, measurable, achievable, and aligned with your organization’s mission, vision, and values.

4 – Develop processes

Develop application and evaluation processes for your clinical ladder program. The processes should be fair, transparent, consistent, and involve both self-assessment and peer review. They should also include methods for feedback, recognition, and rewards for the nurses who apply and achieve the clinical ladder levels.

5 – Pilot and implement

Consider a pilot phase involving a small group of nurses who volunteer to test the program and provide feedback. The implementation phase should involve a wider rollout of the program, with ongoing communication, education, and support for the nurses who participate.

6 – Monitor and evaluate

Program evaluation should include both quantitative and qualitative data, such as the number and percentage of nurses who apply and achieve the levels, the impact of the program on nurse retention, satisfaction, performance, and patient outcomes, and the feedback and suggestions collected from nurses and other stakeholders.

Determining the levels of your clinical ladder program

The levels of a clinical ladder may vary depending on the specific design and objectives of the program, but they generally follow a common progression from novice to expert previously documented by researchers. Here is an example of program levels:

Level 1: Novice — This is the entry level for nurses who are new to the profession or specialty. They demonstrate basic clinical knowledge and skills, follow policies and procedures, and seek guidance and feedback from more experienced nurses.

Level 2: Advanced Beginner — This is the level for nurses who have acclimated to their role and can carry out more responsibilities independently. They use their limited prior experience along with learned procedures and rules to determine their course of action but may still rely on support from other team members as they develop their knowledge.

Level 3: Competent — This is the level for nurses who have gained some experience and confidence in their clinical practice. They demonstrate competence in clinical judgment and decision-making, apply evidence-based practice, and collaborate with other healthcare professionals.

Level 4: Proficient — This is the level for nurses who have developed a high level of clinical expertise and proficiency in their specialty. They demonstrate leadership and innovation in clinical practice, initiate and participate in quality improvement projects, and mentor and educate other nurses.

Level 5: Expert — This is the highest level for nurses who have achieved excellence and mastery in their clinical practice. They demonstrate advanced clinical knowledge and skills, influence their healthcare system, help shape the nursing profession, and may even conduct and disseminate research.

Nursing clinical ladder examples

There are many examples of nursing clinical ladder programs in different healthcare settings. Here are some examples you can adapt for your own organization:

  • The Clinical Advancement and Recognition Program for Nurses (CARP) at Penn Medicine is a six-level clinical ladder program that recognizes and rewards nurses for their clinical knowledge, professional achievements, and contributions to patient care. The program provides advancement opportunities for nurses who choose to focus on clinical practice. Nurses can advance from the first to second level within two years of hire.
  • The Duke Health Clinical Ladder Program helps advance the careers of clinical staff through advancement opportunities such as education, increasing levels of responsibility, and increases in compensation at each level. Professionals in a range of clinical roles are eligible, including nurses, who can obtain specialty certifications through the program.
  • The Clinical Advancement Program (PACE) at Johns Hopkins is a five-level clinical ladder program that recognizes and rewards bedside nurses with structured salary increases based on the attainment of experience and competencies that lead to increased clinical responsibilities.

Education is the foundation of a clinical ladder

A nursing clinical ladder program is a valuable tool to retain, motivate, and develop your nursing staff. It can help create an organizational culture of clinical excellence, professional growth, and leadership. It can also improve nurse performance and patient outcomes, support nurse recruitment and retention, and reduce nurse turnover and burnout.

Organizational learning and development are a critical piece of your clinical ladder program. In addition to gaining skills on the job, your healthcare professionals need quality training to advance.

Does your organization have a robust healthcare education platform that provides the knowledge and skills your nurses need to take their next step on the clinical ladder? The learning you supply directly correlates to the proficiencies they attain and the care they provide to your patients.


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Relias provides award-winning, accredited courses across the entire care continuum. In addition to our expert-built clinical content and education, our workforce enablement solutions improve healthcare delivery through continuing education, professional development, certifications, and compliance — to empower your teams to be the best they can be.

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