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Revising a clinical ladder program to increase nurse participation

By: Wendy Reich, MSN-Ed, RNC-OB, C-EFM, CBC; Danielle Hilliard, MSN, APN, RN, CPNP, CCRN-K; and Marybeth Gartland, MSN, RN, CCRN-K

A community hospital recognizes a need and builds a program to meet it.


  • To recruit and retain a strong, competent nursing workforce, healthcare organizations must provide programs that support new nurses, beginning with onboarding and throughout their careers.
  • The ideal clinical ladder program should engage nurses, be easy to understand and navigate, and adapt to changing needs.
  • The purpose of PDAP is to encourage clinical nurses’ professional development and advance their individual practice.

Let us never consider ourselves finished nurses. We must be learning all of our lives.” This quote, attributed to Florence Nightingale, is especially relevant today as nurses seek working environments that provide professional growth and development through concrete orientation and new graduate residency programs, mentorships, and ongoing educational opportunities that pro­mote clinical and critical thinking skills. To recruit and retain a strong, competent nursing workforce, healthcare organizations must provide programs that support new nurses, beginning with onboarding and continuing throughout their careers. (See Climbing the ladder.)

Climbing the ladder

Clinical ladder or professional advancement programs were developed to recognize and promote:

  • professional development
  • quality patient care
  • job satisfaction
  • nurse retention.

These programs reward (frequently with financial incentives) outstanding nursing practice at the bedside and within organizations. Nurses can climb clinical ladders by participating in performance improvement and/or nursing research projects, and they can distinguish themselves as experts in their clinical settings. Recognition and rewards improve job satisfaction, which in turn increases staff retention and decreases turnover rates.

Recognizing a need

The ideal clinical ladder program should engage nurses, be easy to understand and navigate, and adapt to changing needs. Without these elements, the program won’t be sustainable. We learned that at our community hospital (Monmouth Medical Center) in 2015 when we realized that our decades-old program didn’t adequately reflect the work nurses were doing on the unit, hospital wide, and even in corporate activities outside of their nursing jobs.

Program survival required modernization that incorporated current healthcare trends and organizational standards. To revise the program, a team of nurse educators reviewed the literature and developed a tool based on Jean Watson’s Theory of Human Caring and the Clinical Caritas Processes. To apply to the clinical ladder programs, nurses were required to write a 250-word essay that described a positive patient outcome or experience. The goal was to give them autonomy and flexibility about how they would participate in the program.

The new program was presented at a hospital-based shared governance council, and modifications were made based on the council’s input. The new program launched in April 2016. All eligible nurses were encouraged to apply, and the clinical education department developed training and workshops to inform and engage staff and provide application process support. About 10% of eligible nurses applied.

After the initial excitement fizzled, the program’s success couldn’t be sustained; 2 years later, less than 2% of the nursing staff remained in the program. A significant challenge was that the program was primarily the responsibility of two clinical educators who didn’t have expertise in all subspecialties and struggled to understand what nurse research or performance improvement projects entailed. This was frustrating for both educators and staff.


To better understand the frustration and lack of interest, the education team conducted focus groups with nurses from different units and levels of expertise to investigate why they were leaving the ladder program. Nurses told us they found the program difficult to navigate and that it wasn’t concrete enough. They had difficulty writing narratives and found the application too vague. In addition, they felt the program was cumbersome and struggled to meet the criteria. Some nurses said, “Just tell me what to do and I will get it done.”

We also conducted focus groups with nurses who weren’t participating in the program and asked what prevented them from applying. They felt they had no time to complete the paperwork and that they didn’t know how to navigate the application to meet some of the criteria. Some more experienced nurses didn’t have a bachelor of science in nursing (BSN) degree (nurses in the program were required to have a BSN or be actively working toward it) and weren’t interested in enrolling in a college program at this stage in their career. Also, many felt the financial incentive wasn’t enough to make the program worth it.

Starting over

The nursing educators reassembled in 2017 to once again review the clinical ladder program. We conducted a literature search to identify components of successful programs, and we reached out to other organizations in our health system to learn what made their programs successful. If we found a component we liked at a successful program, we obtained permission to duplicate it. We wanted to capture what nurses were doing to promote themselves professionally and how bedside nurses were enhancing quality patient care on a daily basis. We also wanted to recognize nurses who mentor and serve as positive role models for safe practice. We sought out nurses within the organization who were members of unit councils and shared governance to identify the critical elements of nursing practice and make sure they were reflected in the new program. And because our facility was on the American Nurses Credentialing Center (ANCC) Magnet® journey, we took the opportunity to align our program with the Magnet Model components.

Leadership support

Our literature review indicated that the success and sustainability of a program requires support from nursing leadership and administration. We met with our leaders to discuss the decreasing number of nurses in the program and to look at increasing the financial incentives. We shared what we envisioned for the new program, including a more professional name. The name was changed to Professional Development Advancement Program (PDAP).

Nursing generations

In redeveloping our program, we acknowledged that the nursing staff comprised a wide range of experiences and four generations of nurses working at the bedside. In our literature review, we learned that nurses just starting their careers seek employment in supportive work environments that focus on quality and safe patient care. They want to be rewarded for their efforts, and they want employers to guide them as they transition into practice. These new nurses look to their employers to help them advance their skills, and they want opportunities to advance.

Mid- to late-career nurses want to remain employed in the profession if their work environment is positive and supportive of older workers. They want a professional culture that respects and recognizes their wealth of experience and dedication to their employers.

Considering these generational differences, we wanted our program to be relevant for all nurses personally and professionally.

Building the new program

The purpose of PDAP is to encourage clinical nurses’ professional development and advance their individual practice. The new program outlines the experience, critical thinking skills, education, and professional activities required of nurses seeking advancement. It provides nurses with opportunities for growth and development and a consistent framework for progress. And it’s designed so nurses at all levels and experiences can participate.

The program consists of four levels that are aligned with the ANCC Magnet Model components and focused on improving empirical outcomes. Nurses have opportunities to achieve points under each component; the number of points determines their PDAP level. By modeling our nursing practice around the Magnet components, the overall goal is to achieve nursing excellence by creating a culture that’s focused on delivering high-quality, evidence-based care, continual improvement of empirical outcomes, and greater patient and staff satisfaction. (See Point by point.)

Point by point

Professional Development Advancement Program point system

The Center for Professional Development, Innovation and Research at Monmouth Medical Center in Long Branch, New Jersey, developed the following form and accompanying point system to guide nurses as they climb the Professional Development Advancement Program clinical ladder.

Level 1: New knowledge, innovations, and improvements
Skill elements Points My points
**Principal investigator/co-investigator for IRB-approved study (research project documentation) 1  
Ongoing data collection for an IRB-approved research study (research project documentation) 1  
Presentation of research study/conference poster/podium presentation 2  
Participation in the nursing research committee 1  
Performance improvement data collection 1-2  
Quality Improvement project/performance improvement project 2  
Development of standard of care/revision of policy or procedure 1-2  
**EBP presentation at the EBP journal club (required for all levels) 1  
**EBP activity that results in: (choose one)

__practice improvement __improved department efficiency __improved patient safety __improved understanding of patient and/or team member diversity

**Required for levels 3 and 4

Other: 1  
Level 2: Exemplary professional practice
Skill elements Points My points
Certified instructor of BLS, ACLS, NRP, etc. (must teach one program) annually 1-2  
Development/presentation of program with/without contact hours 1-3  
Case study presentation 1  
Patient/staff education presentation 1-2  
Skill certifications (nonjob requirement) 1-2  
Read and review an article using the John Hopkins tool (same article can be used at a journal club)


Participate on the Monmouth Medical Center EBP council 1  
Complete the RWJBH CITI training 1  
Complete 10 contact hours per year (5 must be specialty specific) 1  
Sit on PDAP council 1  
Other: 1  
Level 3: Structural empowerment
Skill elements Points My points
Participate in health-related community service activity (maximum of two submissions) 1  
Develop/manage health-related community activity 2  
Professional award/recognition: inhouse, regional, or national (maximum of two submissions) 1-3  
Currently enrolled in BSN, MSN, or DNP program 1  
Professional national-approved certification (points awarded for first time-certification only) 3  
Professional national-approved certification (maintenance) 1  
Current membership in professional nursing organization 1  
Competency/skills validator 1-2  
Special Needs Ambassador Program (active resource participant) 1  
Published article: inhouse, regional, or national (maximum of two submissions) 1-3  
Nominated for “I Made a Difference” 1  


Level 4: Transformational leadership
Skill elements Points My points
Active officer in professional nursing organization: local, regional, national 1-3  
Active membership in professional nursing organization (board member, etc.) 1  
Active officer in unit/hospital committee 2  
Active membership on unit/hospital committee 1  
Preceptor of new team member 1-2  
Charge nurse 1-2  
Other: 1  

ACLS = advanced cardiac life support, BLS = basic life support, BSN = bachelor of science in nursing, DNP = doctor of nursing practice, EBP = evidence-based practice, IRB = institutional review board, MSN = master of science in nursing, NRP = neonatal resuscitation program, PALS = pediatric advanced life support, RWJBH CITI = Robert Wood Johnson Barnabas Health Collaborative Institutional Training Initiative

PDAP incorporates Patricia Benner’s theoretical framework and Jean Watson’s philosophy. Together, they provide the outline for nurse professional growth and development and incorporate principles of the caring-healing environment. (See Putting theory into practice.)

Program rollout

Learning from the past program, all clinical educators are now responsible for nurses applying to the program in their respective areas of expertise, allowing the educators to provide better direction with project development and performance improvement. The educators follow their assigned staff more closely and help them stay on target with their projects. In addition, they encourage and mentor new staff applying to the program.

The education rollout took the entire summer of 2018. Education consisted of clinical educators attending unit council, shared governance, staff, and one-on-one nurse meetings. We also conducted informational sessions and workshops so nurses could ask questions and get help building and reviewing their applications. In addition, the educators guided nurses as they developed performance improvement projects and research. The initial feedback was positive, and staff felt that the new point system was easier to understand and more concrete than the previous program.

Our goal was to increase eligible nurse participation by 20%. We began accepting applications in the fall of 2018. We had 91 applications submitted and approved, meeting the 20% goal; participation increased by 30% from 2016 and by 911% from 2017.

Putting theory into practice

Our Professional Development Advancement Program (PDAP) incorporates Patricia Benner’s Novice to Expert Model and Jean Watson’s Theory of Human Caring.

Novice to expert

Using Benner’s Novice to Expert Model, the PDAP objectives allow nurses to progress professionally and facilitate and enhance a nursing practice that reflects our organization’s nursing mission, vision, and philosophy. Benner identifies the nurse advancing from novice to expert in four levels, which align with the PDAP levels:

  • Level I—Novice
  • Level II—Competent
  • Level III—Proficient
  • Level IV—Expert

As we work toward American Nurses Credentialing Center Magnet® recognition, we asked our shared governance committee to reflect on the components of our professional practice model and integrate them into the PDAP point system.

Human caring

Watson defines nursing as a therapeutic interpersonal process based on the philosophy and science of caring, which is a moral commitment to preserve human dignity. Nurses achieve this through human caring activities identified as the 10 “Clinical Caritas Processes.”

As part of the PDAP application process, nurses seeking any level of the clinical ladder write an essay about their personal practice that incorporates our organization’s professional practice model and the Clinical Caritas Processes.

Meeting nurses’ needs

Since the inception of the new program, feedback from staff has been positive, and 150 nurses currently are enrolled in the program (to date, no nurses have dropped out). Staff can apply quarterly, and we’re finding that each quarter new staff apply. We’ll continue to monitor the program and modify it as necessary to ensure it meets the needs of today’s nursing workforce.

The authors work in the Center for Professional Development, Innovation and Research at Monmouth Medical Center, Long Branch, New Jersey. Wendy Reich is a clinical educator, Danielle Hilliard is the administrative director, and Marybeth Gartland is a clinical educator.


Armstrong-Stassen M, Cameron S, Rajacich D, Freeman M. Do nurse managers understand how to retain seasoned nurses? Perceptions of nurse managers and direct-care nurses of valued human resource practices. Nurs Econ. 2014;32(4):211-8.

Lippincott Solutions. Level up! 4 steps in creating an effective clinical ladder program. August 30, 2018.

Price S, Reichert C. The importance of continuing professional development to career satisfaction and patient care: Meeting the needs of novice to mid- to late-career nurses throughout their career span. Adm Sci. 2017;7(2):17.

Ries E. Ladders that matter in clinical care. PT in Motion. 2016;8(3):16-24.

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