A clinical advancement process revisited: a descriptive study

A clinical advancement process revisited: a descriptive study

Cynthia W. Ward

A clinical ladder was implemented in 1991 at a community hospital in central Virginia to offer promotion opportunities beyond the traditional administrative or education roles by fostering professional growth, skill development, and monetary compensation for nurses who wished to remain at the bedside. The ladder consisted of four levels and was based on Patricia Benner’s From Novice to Expert (1984).

The first evaluation of the advancement process at this community hospital was conducted in 2000 due to decreasing numbers of applicants, the advancement committee’s concern as to the perceived value of the advancement program by administrators and staff nurses, and the task-oriented emphasis of the criteria. The evaluation found pay to be the most important, yet least satisfying element identified by respondents to the survey (Stamps, 1997), with autonomy and professional status the second and third most important elements (Goodrich & Ward, 2004). Themes identified in personal interviews with staff nurses included the ladder’s task orientation and a belief that advancement did not necessarily equal excellence in bedside care. Concerns also were expressed regarding part-time staff members’ exclusion from advancement to the higher levels of the ladder.

Findings of the first evaluation prompted changes in the advancement criteria and the application and interview processes. Criteria were rewritten to be more outcomes based and to place more emphasis on research utilization at all practice levels. Modifications to the advancement criteria offered more flexible options to satisfy requirements, and professional activities were scheduled during nurses’ work time. The submission of a clinical exemplar for advancement to levels III and IV was a new requirement. Advancement criteria were categorized into initial eligibility, annual mandatory, and annual elective areas. Annual elective criteria were divided into the following categories, based on the annual performance appraisal: competency, customer service, teamwork, quality, and continuous learning. Registered nurses (RNs) working a minimum of 1,200 hours annually were allowed to advance. Additionally, RNs were allowed to transfer across divisions without loss of status, having 6 months to meet competencies in the new area. Previously, they had been required to return to level II and then re-apply for advancement (Goodrich & Ward, 2004). A full description of the hospital’s clinical ladder process, the evaluation, and changes to the program were published previously in MEDSURG Nursing (Goodrich & Ward, 2004).

A Review of the Literature

In the past, the only avenue for nurses who were clinical experts, or who wanted to advance their careers was to move into education or management (Balasco & Black, 1988; Hamric, Whitworth, & Greenfield, 1993). As early as the mid-1960s, the need was identified for a system to retain clinical nurses at the bedside and recognize their expert skills (Creighton, 1964). Clinical ladders were first implemented in the 1970s to retain nurses and recognize nurses who stayed and excelled at the bedside. However, many of these early ladders focused on measurable tasks rather than nurses’ clinical proficiency (Hamric et al., 1993).

Clinical advancement programs are recognized as methods to improve the quality of patient care and reward nurses for clinical competence (Joel, 1990). In addition to recruitment and retention of nurses, Vestal (1984) identified career ladders as a way for hospitals to increase job satisfaction and financial compensation, and as tools for increased productivity. Schultz (1993) noted that supporting the professional growth of new staff members was another function of advancement programs. Because nurses enter the workforce with different levels of education and skills, clinical advancement programs may influence professionalism and dedication to the career (Krugman, Smith, & Goode, 2000).

The 1981 study by the American Academy of Nursing, which identified the components that later came to personify Magnet[R] hospitals, recognized the importance of the professional development and promotion opportunities afforded by clinical ladders (McClure, Poulin, Sovie, & Wandelt, 2002). This same study found that clinical ladders are a positive component motivating professional development and recognition for clinical competence.

Role changes are assumed to occur in addition to the reward received upon promotion in an advancement program (Schultz, 1993). To be successful, career advancement programs must define these role expectations clearly while simultaneously maintaining the bedside direct care role. Nurse manager support also has been identified as an essential element as staff members adopt new role responsibilities (Schultz, 1993).

Nurse involvement in the planning of career advancement programs is considered vital, both for the success of the program, and the productivity and motivational outcomes related to it (Vestal, 1984). Little information in the nursing literature relates to evaluation of clinical advancement programs by staff nurses (Schmidt, Nelson, & Godfrey, 2003). The advancement program described in this article was developed originally with staff nurse involvement. The evaluation and revision of the program were accomplished and implemented entirely by staff nurses.


The current study was conducted as a re-evaluation of the substantial changes made to the structure of this hospital’s clinical advancement process after the initial review 2 years earlier. The intent was to determine if the changes in the process met the needs of the participants, if the process was supportive of professional practice, and if further changes in the program were necessary. The survey was conducted by the first author of this article, who is also the co-chair of the clinical advancement process committee (CAPC) at the hospital.


A convenience sample of all RNs in the clinical advancement program (n=960) was identified by the human resources department. A survey was sent to each RN on his or her assigned patient care unit. Completion of the survey was voluntary and to ensure anonymity, no names were required on the survey. All responses were sent to a central location–the hospital’s nurse retention specialist–who gathered all responses for the researcher. The surveys were coded to identify the participants’ level in the advancement program, but there was no coding to identify an individual respondent. The participants were informed that their responses would be reported as aggregate data.

Procedure. A proposal for the study was presented to the research council, the CAPC, and the senior vice president of patient care services, and was reviewed and approved by the institutional review board. Participants received the surveys through the organizational mail system and were instructed to return the surveys via the same system to the retention specialist. Data were entered into SPSS and analyzed using descriptive statistical methods.

Instrument. The Clinical Ladder Assessment Tool, which measures the effectiveness of clinical ladder programs, was used with permission of the author Dr. Sarah Strzelecki. It included general information about the area of nursing practice, the number of steps in the clinical ladder, the respondent’s position on the clinical ladder, level of education, and years of experience. Additional questions addressed the areas of differentiation of levels of nursing clinical competence; reinforcement of responsibility and accountability in nursing practice; guide for evaluation of clinical performance; opportunities for professional growth; rewards and benefits commensurate with levels of practice; job satisfaction through recognition for clinical practice; and provision of increased levels of autonomy and decision making (Strzelecki, 1989). Open-ended questions regarding reasons to motivate advancement, barriers to applying, and the efficacy of the advancement program specific to the hospital’s clinical advancement process from the initial evaluation in 2000 also were included.


The response rate was 18.3% (n=176). Most respondents were diploma nursing graduates (n=93, 54%) at the RN II level (n=98, 55.6%), with 0-5 years of experience (n=43, 26%). The majority were employed in adult medical-surgical (n=44, 28%) or adult critical care settings (n=42, 26%) (see Table 1).

Respondents indicated a belief that the advancement program stimulates greater responsibility and accountability in their practice. Responses from nurses at the higher levels of the program indicated an increased professional view of their practice. Respondents indicated they had increased responsibility and decision-making opportunities as they advanced (level II = 68%, level III = 84%, level IV = 76%). In regard to use of personal initiative and judgment in the provision of care, 59% of level II respondents indicated these were encouraged by advancement, while 80% of level III and IV respondents held that opinion. The advancement process was perceived to encourage increased knowledge and sophisticated nursing skills by 90% of level IV respondents, 74% of level III, and 57% of level II.

Responses related to opportunities for professional growth also varied according to current level on the advancement program; 64% of level II, 78% of level III, and 90% of level IV respondents perceived that the advancement program provides opportunity for promotion for the nurse remaining in clinical practice. Additionally, 90% of level III and IV respondents indicated the clinical advancement process encouraged them to be a role model for new staff; 70% of level II nurses agreed. Of nurses at level III and level IV, 80% and 78% respectively indicated the clinical advancement process increased their awareness of the need to describe the rationale for their care, validating their understanding of the increased accountability; 57% of level II respondents agreed.

Although 73% of respondents agreed that the clinical advancement program provided them with a sense of accomplishment and professional satisfaction about their work and career choice, the presence of a clinical advancement program was not identified as an important factor in seeking or continuing employment at the hospital. Only 25% of respondents identified the clinical advancement program as a major factor in continuing employment, while 34% would not consider employment in a setting without an advancement program.

The open-ended questions revealed that nurses at all levels of practice identified monetary compensation as the most important motivator prompting them to seek advancement. This is consistent with the findings of the 2002 program evaluation (Goodrich & Ward, 2004). Peer recognition also surfaced as an important factor in making a decision to pursue advancement. Personal time constraints were cited most frequently as a barrier to making a commitment to the responsibilities of advancement, followed by the perception that the advancement process itself is intimidating. Staff members generally did not see practice differences among those who have advanced, and the need for more unit manager involvement in supporting staff through the advancement procedure was articulated by respondents. These findings, which are consistent with the 2002 evaluation, deserve further study as the advancement program continues.


The surveys were sent to the participants on the nursing units through the hospital mail system, with no way to ensure that the surveys reached the intended participants. The inconsistent method of distribution of inter-hospital mail may have affected the number of participants who received the survey in time to complete it by the response deadline. Although anonymity was assured, some participants may have been reluctant to return the completed survey through inter-hospital mail. The limited number of responses may not give an accurate representation of the opinions of the majority of the staff. The survey instrument allowed only yes or no responses; if a question didn’t apply to a participant, he or she was forced to choose one of these responses or leave the item blank. Eighty-six surveys were returned with all data points complete. Of those that were incomplete, most of the missing data were demographic. Therefore, no surveys were excluded based on missing data.

Discussion and Implications

A knowledge deficit about the clinical advancement process was identified in several areas. The number of advancement levels in the current program was named incorrectly by 20% of respondents; 45% stated either they did not understand the process at all or somewhat understood the process. Additionally, the responses to the open-ended questions showed a lack of understanding of the current criteria and requirements for advancement. This lack of knowledge was most evident among nurses at the second level on the program.

Despite the fact that a comprehensive manual identifying the criteria and process for advancement was located on each nursing unit and on the hospital’s Intranet, 54% of respondents stated they received the most comprehensive and accurate information about the clinical advancement process from nurses who had been advanced previously. Unit managers are required to write letters of recommendation for applicants and are expected to counsel potential applicants, yet only 8% of respondents noted that they receive the best information about the process from their unit managers. This may suggest that the nurses are unaware of the manual’s existence or location, the information in the manual is unclear, or the nurses are more comfortable asking their peers for information than reading from the manual or asking unit managers.

Recent Changes in the Process

Prior to the 2000 evaluation, no major changes had been made in the clinical ladder process since its inception in 1991. Following the revision in 2002, the CAPC made changes in response to changing nursing practice and the changing needs of the staff. Following the initiation of shift manager positions on all nursing units for evening and night shifts, the requirement of maintaining the ability to assume the charge nurse role was changed from an annual mandatory requirement to an elective requirement. In September 2004, the process was modified to allow patient educators to be eligible for advancement. Before this change, RNs moving from a level III or IV bedside care position to a patient education position lost their ladder designation. Flexibility has been added to the program for any nurse who wants to seek a nonclinical opportunity within the organization. The individual now has the option to return to the bedside if so desired without penalty of losing ladder designation. For example, a clinician at the III or IV level who accepted an assignment developing the new computer system may return to bedside nursing at the former level, with the expectation that criteria for that level will be met again within 1 year.

Upon recommendation by the professional practice council, changes were made in the process for advancement from RN I to RN II. Council members asked that new graduates advance to the RN II level within 12 months with submission of a portfolio to the unit manager. That portfolio would include the applicant’s resume or curriculum vitae; absentee rate; a copy of the most recent evaluation; evidence of completion of orientation competencies; a copy of the continuing nursing education record, including mandatory inservices; two peer reviews; supporting documentation of eligibility criteria; annual mandatory requirements and annual elective requirements; written goals; and a brief clinical narrative. In collaboration with the professional practice council, members of the CAPC modified the submission requirements and peer evaluation tool for the RN II. New requirements are based on the level III and IV requirements, and the hope is that the experience of preparing a portfolio at the second level will help prepare nurses for advancement to the higher levels in the future.

After the hospital attained Magnet designation in 2005, the advancement program focused on demonstrating how the forces of magnetism are being exhibited in the practice setting (American Nurses Credentialing Center, 2004). Applicants now are required to relate their clinical exemplar to the forces of magnetism. The committee works in collaboration with the nurse executive council in the shared governance structure to develop and enhance the advancement process continually in response to the needs of the organization, the staff, and the profession.

Implementing Changes Based On Findings

The survey’s strong indication of a need for more education resulted in the CAPC launching an education initiative. Members of the committee attended the hospital’s Nurses Week celebration to provide information and answer questions about the program, display samples of portfolios of successful applicants, and offer demonstrations on accessing the program information online. A PowerPoint presentation was developed and added to mandatory online education for each clinically based RN. Instructions to access the online manual were provided to all nursing staff by email. Education programs about the clinical advancement process and unit managers’ responsibilities related to the process were presented to all unit managers during their scheduled leadership meetings.

The CAPC increased efforts to publicize the accomplishments of the advancing nurses after 58% of survey respondents noted advancement should be accompanied by public and formal recognition. The nurse retention specialist assisted the committee with publicizing the advancements in the hospital newsletter and on the nursing home page on the hospital’s intranet. All nurses at level III and IV were recognized by having their names listed on a poster at the hospital’s Nurses Week celebration.

Program Update

Since the changes made in the program in 2002, activity has remained at approximately double the number of nurses advancing to level III, and 6-II times higher for level IV (see Table 2). The percentage of nurses at each level, however, has remained relatively constant (see Table 3). Future plans include enhancing the involvement and accountability of the unit managers by identifying appropriate candidates. The advancement criteria also will be reviewed and revised as necessary to link more strongly to patient outcomes and further development of the professional practice environment. Plans also are underway to provide a portfolio development class and clinical exemplar workshop.


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Cynthia W. Ward, MS, RNC, CMSRN, is a Registered Nurse IV, Lynchburg General Hospital, and Co-Chair of the Clinical Advancement Committee, Centra Health, Lynchburg, VA.

Cynthia A. Goodrich, EdD, MSN, RN, is Women’s Health Educator and Magnet Coordinator, Centra Health, and an Associate Professor, Liberty University, Lynchburg, VA.

Table 1.

Characteristics of Sample

Characteristic N = 176 Percent

Level on CAP

RN I 9 5.1

RN II 98 55.6

RN III 49 27.8

RN IV 20 11.3

Specialty Area

Adult critical care 42 26

Adult medical/surgical 44 28

Emergency 8 5

OB/GYN 11 7

Operating room 8 5

Other 26 16

Pediatrics 12 8

Psychiatric 8 5


MSN 7 4

MA/MS, other 6 3

BSN 45 26

BA/BS, other 6 3

ADN 13 8

Diploma 93 54

Years of Experience in Nursing

0-5 43 26

6-10 32 19

11-15 18 11

16-20 22 13

21-25 21 13

26-30 16 10

31-35 11 7

36+ 3 2

Table 2.

Number of Nurses Earning Advancements


2001 14 1

2002 28 8

2003 28 7

2004 29 6

2005 48 11

2006 (through June) 19 4

Note: 960 nurses were eligible.

Table 3. Comparison of Number of RNs Per Level

2000 (n = 1,000) 2004 (n = 960)

RN I 99 (10%) 63 (6%)

RN II 800 (80%) 744 (78%)

RN III 91 (8%) 127 (13%)

RN IV 10 (1%) 26 (3%)

Note: 960 nurses were eligible.

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