Clinical Ladders, Advancement, and Development...Oh My!

Clinical Advancement can be a great way to get ahead with your career and move forward at work, as more of a leader. But it can be hard to hold people to the various levels of expectations; what happens when the advancement process is inconsistent and when people aren't held accountable? How do you feel about advancing clinically?

Clinical Ladders, Advancement, and Development...Oh My!

When I started my first job as a Medical-Surgical nurse on a solid transplant organ unit, I was so nervous, all I could focus on were the tasks in front of me, learning medications, and keeping my patients safe. I had no interest in a clinical ladder or advancing with any extra work because I could barely keep my head above my direct patient care responsibilities. As I started to go from a novice nurse, to more competent and I began to be seen as a leader on my unit, so I started to think about clinical advancement; it seemed like a real honor, so I completed my application and moved along with my advancement! Did my practice change? No, other than I pushed myself to constant betterment. Did anything else change as far as leadership on the unit? Nope. It seemed like a bit of a let down.

Four years later, I was completing my MSN, I realized that I was eligible to advance, yet again. I spoke to my Clinical Nurse Specialist about advancing to the highest advancement, which is considered an "expert". Seeing as I was viewed by my peers as a leader on the unit, I used evidence based practice as my basis for clinical judgment, and I was, in the eyes of many of my co-workers, an expert. When I broached the topic with my CNS, I remember her telling me: "You're just not there yet." And I was crushed. I was mad. I was in disbelief. When there were plenty of other nurses on my unit, and elsewhere in the hospital, that had advanced, yet based their practice on the "this is how I've always done it" model of nursing, and some of which had really sour attitudes, I truly felt that it was wrong that I wasn't allowed to apply. I felt I deserved the recognition...and that raise that came with it!

I began to think about the advancement program in general:

Was it truly such a subjective decision for one person in unit leadership to make? Why did I even care about advancing, besides the raise?

What else did it do for me?

Why should I even waste my time?

From that point forward, I never looked back, and I continued to grow as a clinical nurse and worked as a Clinical Nurse Specialist from that point forward.

Ironically, as a CNS, for the past 18 months, I have been a part of a workgroup that is revamping the Clinical Nurse Advancement Program at my hospital, previously referred to as the Clinical Ladder. We have been looking at the program from every angle, and I realized that the biggest challenge with the program is what I experienced: consistency and accountability. Nurse Managers, Clinical Nurse Specialists, and staff nurses alike all felt there was a lack of consistency with the process of who applied for advancement: some units had the manager approve the applicant before the process started, some units (like mine) had a process where the CNS had to approve the applicant, and other units/areas, staff just decided independently that they were suitable to apply, and they did. The lack of consistency became more and more apparent, and staff nurses became more vocal about the process and what they didn't understand, or feel was fair. As someone who was in the same situation eight years prior, I have been able to speak to those feelings of some of the current staff nurses, and the fact that some of the people clinically advanced, when I was not "allowed" to apply, didn't have the same attributes and attitude towards nursing as I did (and I in no way mean to make myself seem like Super Nurse who swooped in and saved the day in a swirl of white scrubs, smiles, and glitter...just someone who researched everything and gave my patients and their families the best care I could give them, even if that meant a fight with the residents, every single day!)

Which leads to accountability; the expectation is that an expert nurse is not only an expert at tasks, a leader in the unit, but takes their leadership skills to hospital-wide initiatives, and has a really positive attitude. I will tell you, there are some nurses out there with poor attitudes, I think we all know who I am talking about; the ones that you wonder how they wake themselves up every morning to get to a job that makes them so miserable (interestingly, usually totally charming to their patients, just not pleasant to work with). They may have great practice and skills, but not someone you get amped to see matched on almost every shift in your next schedule. They may have been pleasant at one time, but somewhere along the line things changed, and now they are at the highest level of advancement, a leader on the unit, yet new nurses are too scared of them to talk to them, they refuse to precept, and no longer take part in any work outside of the unit, etc.. So, do we just leave them at the highest level of advancement, yet they aren't really seen that way? Or should we hold them accountable for the expectations for the advancement and if they do not meet expectations, they are demoted and lose the salary equivalent for the advancement?

After 18 months, we have made many changes, and made standardization of the application one of the biggest focuses, to ensure consistency, along with the accountability piece. We created a whole education piece for managers, CNSs, and other unit leadership, so that all applicants need to meet certain criteria, then get manager approval, and then move forward with the process. As well, we have standards to hold staff accountable: we made new job descriptions, so when you advance, you are accepting a new role at the hospital, not just an imaginary change in your position, you are truly being promoted. It's a new and different approach to clinical advancement, and it is more of a professional advancement. We are just starting the education, and rolling this out, but so far, it has been seen in a totally positive light.

What do you think, would you advance if it meant you were being held accountable to a new job description as well? Do you have a clinical ladder/advancement program that seems inconsistent?

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Bridgid Joseph

About Bridgid Joseph, BSN, MSN, APRN, CNS

Clinical Nurse Specialist, Emergency Cardiovascular Specialty: Surgery,Critical Care,Transplant,Neuro

14 Articles   67 Posts

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Specializes in Critical Care.

Interesting approach especially about giving them a new role position in the hospital, not sure how that actually works do they have a new name to their position? Yet they are still staff nurses right. What I disagree with is a ladder system that offers a one time raise, but follows that with the threat of a demotion and pay cut in the future which is what you are advocating for if I understand you correctly. Nursing is the only "profession" that offers you a raise and a promotion with the threat of a paycut and demotion at the same time. Totally makes no sense to me, makes a lie of being a professional. What professional is treated that way.

I've been a staff nurse for many years and consequently seen many different ladders rolled out over the years, changed and revamped, from point systems to resumes, committee work, and coincidentally now renaming ours as well. Personally think the name change is silly, doesn't change the system. The majority of nurses become Level III, a few advance to Level IV, mostly for money and if they have admin ambitions. Of course I know of more than a few people who have been demoted as well, which seemed arbitrary to me and insulting, certainly not a way to retain staff or morale, but I bet you would disagree there! I had a friend on the ladder committee with other admin who were bragging about their $300-400,000 houses one minute then voting to demote a nurse the next. Pretty sad all the way around if you ask me. I chose not to climb the ladder, and yes it has cost me some money, but it has kept my dignity and sanity intact and I don't have to look over my shoulder and wonder if I'm going to be demoted or have to jump thru ever changing hoops just to keep a one time pittance of a raise!

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Specializes in Surgery,Critical Care,Transplant,Neuro.

Brandy, I appreciate the read, and your comment! Maybe I wasn't clear that I am not advocating for people to be demoted in any way, or to take money away from staff! We wanted to be able to hold people accountable to their dedication to the advancement of their profession, which is why we created a new job role, in which your actual role does change, so you are a staff nurse, but you would be called a clinical nurse III or IV, with the expectations that you will maintain the behaviors and activities of that level of advancement, so it is truly a change in position. On top of annual raises, the bonuses you receive each time you advance, and the protected time to work on unit based or hospital wide projects really do make it a financial benefit to staff; it ends up being a lot of money. It is interesting that the main focus of the revamp was to be more positive, make it a more standard process, easier for staff to advance (creating more support to create a portfolio, making a staff peer support network out of advanced nurses), etc. and really the change in job role was to keep it professional, and make it more prestigious. No one is looking to take anyones job/money/etc., I promise! :) The intent is really to have staff take this seriously so that they are more involved in advancing the professionalism of the staff all over the hospital; not to focus on the negative.

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Specializes in NICU, ICU, PICU, Academia.

Great article! I literally just returned from 'grading' Clinical Ladder binders as a member of the committee that oversees the project at my place of practice.

Our model is such that every eligible nurse can apply. Many do- and few complete. For example, the two managers I graded for had 1/11 and 8/13 completions. However, there is little to no recognition for CL. (There is a substantial bonus lump sum awarded based on the number of hours you worked in the previous year.)

In fact, our institution just took away the badge hangers that were awarded to certified nurses. (The laminated part that hangs behind you ID and says 'Certified RN' in big letters. VERY unpopular decision!)

I am forwarding a link to this discussion to the powers that be.

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Specializes in orthopedic/trauma, Informatics, diabetes.

We have clinical ladder pins. Some choose to wear, some don't. We get a raise at CN III and CN IV; CN II is a one time bonus. I find it interesting that we have some CNIII that there is no way they have met criteria. I just finished BSN and my specialty certification. I have a project in the works that I am hoping will allow me to get my CNIII this summer. I think it is important for nurse to be involved.

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Specializes in Surgery,Critical Care,Transplant,Neuro.

Thank you for the read and for your support! It is such a difficult conversation to have with staff, and any culture change is usually hit with resistance, but that sounds like a really tough change to remove something from staffs badges? Hopefully this will help with empowering nurses to advance :)

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Specializes in Surgery,Critical Care,Transplant,Neuro.

I agree- way to go!! You are advancing yourself clinically and professionally which is what I hope all of our colleagues strive for!! :)

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Specializes in Medsurg.

I am in the midst of applying for clinical ladder advancement and found your article. Thank you for your insight!

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