JNPD Journal for Nurses in Professional Development & Volume 32, Number 6, E1YE7 & Copyright B 2016 Wolters

B 2016 Wolters Kluwer Health, Inc. All rights reserved.

The Design and Redesign of a Clinical

Ladder Program
Thinking Big and Overcoming Challenges

Geri-Anne Warman, MSN, RN, CCRN ƒ Faye Williams, DNP, RN, NE-BC, OCN ƒ
Ashlea Herrero, MSHQS, LSSGB ƒ Pariya Fazeli, PhD ƒ
Connie White-Williams, PhD, RN, NE-BC, FAAN

stay at the bedside (Ward & Goodrich, 2007). These pro-

Clinical Ladder Programs or Clinical Advancement
grams offered incentives for education and performance
Programs (CAPs) are an essential component of staff nurse
above and beyond basic requirements. Our organization
professional development, satisfaction, and retention.
developed our first advancement program, the Clinical Ad-
There is a need for more evidence regarding developing
vancement Program (CAP), in 2004. In February 2012, a
CAPs. CAP initially launched in 2004. Nurses
revised program utilizing a point system named the Profes-
accomplished tasks in four main areas: clinical, education,
sional Nursing Development Program (PNDP) was
leadership, and research, which reflected and incorporated
launched. This article focuses on the development of the
the 14 Forces of Magnetism. In February 2012, the newly
CAP, how it was revised to meet the needs of the organiza-
revised program was launched and renamed Professional
tion, and the challenges that continue with this program.
Nursing Development Program. The new program was based
on the 5 MagnetA model components, the Synergy
Benefits of Clinical Ladder Programs
Professional Practice Model, and a point system which
There is evidence in the literature on the benefits of Clinical
enabled nurses to utilize activities in many areas, thereby
Ladder Programs. These programs provide financial incen-
allowing them to capitalize on their strengths. The purpose
tives, raise job satisfaction, aid in recruitment and retention
of this article is to discuss the development, revision,
of staff, and recognize nurses for advanced performance
implementation, and lessons learned in creating and revising CAP.
(Hespenheide, Cottingham, & Mueller, 2011). It has been
noted that these programs recruit motivated and compe-
tent nurses and often serve as a roadmap to developing

C
linical Ladder Programs are formal programs
that promote excellence in clinical practice by
recognizing nurses for specific criteria related
to clinical, education, leadership, and research skills (Riley,
Rolband, James, & Norton, 2009). The first Clinical Ladder
Programs were initiated in the 1970s to retain and recog-
nize nurses who were proficient in practice and chose to
Geri-Anne Warman, MSN, RN, CCRN, is Staff Nurse, University of
Alabama at Birmingham Hospital.
Faye Williams, DNP, RN, NE-BC, OCN, is Director of Medical Nurs-
ing, University of Alabama at Birmingham Hospital.
Ashlea Herrero, MSHQS, LSSGB, is Lean Analyst, Center for Nursing
Excellence, University of Alabama at Birmingham Hospital.
Pariya Fazeli, PhD, is Statistical Consultant, Center for Nursing Excel-
lence, University of Alabama at Birmingham Hospital.
Connie White-Williams, PhD, RN, NE-BC, FAAN, is Director of Center
for Nursing Excellence, University of Alabama at Birmingham Hospital.
The authors have disclosed that they have no significant relationship with,
or financial interest in, any commercial companies pertaining to this article.
ADDRESS FOR CORRESPONDENCE: Connie White-Williams, 1056
Jefferson Tower, University of Alabama at Birmingham Hospital, Birmingham,
AL 35294 (e<mail: cwwilli@uabmc.edu).
DOI: 10.1097/NND.0000000000000307
nurse leaders (Adeniran, Bhattachyarya, & Adeniran,
2012). The continued success of such programs is depen-
dent on many factors, including supportive nursing
leadership, passionate nursing staff, and committee mem-
bers that are committed to the program’s success (Burket
et al., 2010). Clinical Ladder Programs are tools used to
promote leadership development and provide strategies
to improve decision-making skills for frontline caregivers.
By participating in these programs, nurses can acquire
skills needed to contribute to healthy work environments,
support professional practice, and influence quality patient
care and outcomes (Fardellone & Click, 2013).
Purposes of the University of Alabama at
Birmingham (UAB) Clinical Ladder Program
University Hospital is a large academic medical center
with two campuses located in the medical district in
Birmingham, Alabama. There are 1,046 beds on the main
campus and 300 beds on the Highlands campus. UAB em-
ploys approximately 3,000 nurses. The purposes of UAB’s
CAP are to encourage professional growth and develop-
ment and to recognize registered nurses (RNs) in staff

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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

nurse roles who have advanced clinical, leadership,
education, and research skills. The program encourages
RNs to function at their highest desired level of profession-
alism, leadership, and clinical competence. It recognizes
bedside nurses who demonstrate excellence in direct pa-
tient care roles and who continually improve the quality
of patient and family care. The advanced RN exhibits UAB
core values and displays a positive attitude toward patients,
families, and coworkers, utilizing teamwork and effective
communication in all aspects of professional practice.
CAP DEVELOPMENT
CAP Committee
The CAP Committee is a nurse-led committee composed of
staff nurses that have advanced to either Level II or Level
III. The purpose of the committee is to strategically plan
daily operations and develop creative ways to enhance
and sustain the program. The members are responsible
for the review of the portfolios, education of staff including
‘‘how to’’ workshops that review the CAP application pro-
cess, and assisting with the semiannual celebration of the
newly advanced nurses. The committee reports to the Cen-
ter for Nursing Excellence (CNE) and is actively involved
with the Evidence-Based Practice and Research Council.
The CNE is staffed with Master’s or Doctoral-prepared
nurses who promote the professional development of
nurses at the bedside. The CNE staff either (a) serve the
clinical units, (b) serve the programs offered by nursing ser-
vices, or (c) incorporate both clinical and programmatic
duties. One of their roles is to promote the Clinical Ladder
Program and encourage staff nurses to participate. The
Clinical Ladder Program is introduced in Nursing Orienta-
tion and the Nurse Residency Program for new graduates.
The nursing professional development (NPD) practi-
tioners, who are titled Advanced Nursing Coordinators
(ANCs), assist staff in completing the necessary responsibil-
ities for the program. The Evidence-Based Nursing Practice
and Research Council Chair, a DNP-prepared nurse, and
the Director of the CNE, a PhD-prepared nurse, are actively
involved with the program. The professional development
practitioners hold monthly Evidence-Based Nursing Prac-
tice and Research meetings and classes to provide
education and hands on simulation for staff.
The CAP committee meets monthly and annually to
evaluate and update the program and determine goals
for the upcoming year. In addition to staff nurses, the com-
mittee is composed of a nursing director, nurse manager,
assistant nurse manager, and an ANC to assure diversified
representation throughout the hospital.
Original Program
The original CAP was developed in 2004 as a result of an
RN satisfaction survey that showed nurses were dissatisfied
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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
with the lack of opportunities to advance while remaining
at the bedside. Patricia Benner’s (1982) Novice to Expert
model provided the conceptual framework recognizing
that nurses gain knowledge and acquire skill throughout
their career beginning at novice and progressing to expert.
As nurses grow and progress through the stages from nov-
ice to expert, they incorporate the concepts of synergy and
patient and family-centered care to achieve positive patient
outcomes. The CAP consisted of two levels, II and III, and
four focus areas to accomplish tasks in clinical, leadership,
education, and research. Participation in the program was
not required; however, it was recommended and open to
all bedside staff nurses.
Eligibility
All nurses are eligible to participate after 1 year of em-
ployment and can enter the program at Level II. A
nurse must remain at that level for 1 year before advanc-
ing. They must serve in a direct patient care role and have
met or exceeded performance standards within the pre-
vious year. In addition, the candidate has to be in good
standing with no written disciplinary counseling within
the previous 12 months. To advance to Level III, staff
nurses must have been employed at the medical center/
organization for a minimum of 2 years, have a BSN, or
have 5 years of experience in their clinical area. A nurse
must achieve Level II before they are able to advance to
Level III.
Challenge to Redesign
In 2010, as part of the nursing leadership goals, the CAP was
challenged to identify ways nurses could be utilized more
efficiently throughout the organization. That challenge,
coupled with ongoing requests and suggestions to make
changes to the advancement process, prompted the idea
of a total redesign of the program. This provided an ideal
opportunity to align our program with Magnet compo-
A
nents and improve our evidence-based practice and
research content. The goal was to increase participation
by offering more options to meet requirements for each sec-
tion and enhance leadership support for the program. A
common theme throughout the literature was the impor-
tance of the nurse manager’s role in the advancement
process. Manager support is a critical component of suc-
cess. According to Allen, Fiorini, and Dickey (2010), it
should be ‘‘an expectation for managers to be engaged
with staff, discussing advancement on an ongoing basis
and developing action plans to achieve readiness for pro-
motion’’ (p. 320).
Redesign
To begin the process of redesign, a task force was formed,
which included nursing leadership and staff nurse represen-
tatives from across the organization. The task force gathered
November/December 2016
evidence through literature search, elicited staff feedback
through surveys and focus groups, and queried other health
systems. The team met monthly for 14 months to complete
the redesign. To assist staff in recognizing that the program
had been completely revised, the name was changed to the
‘‘Professional Nursing Development Program’’ (PNDP).
STEPS OF THE REVISION PROCESS
Components
In 2011, one of the first decisions the team made was to up-
date the activities required for points to coincide with the
components of Magnet: Exemplary Professional Practice,
Transformational Leadership, Structural Empowerment,
and New Knowledge, Innovations, and Improvements. In
each of these sections, activities that reflected desired tasks
and behaviors in the category were assigned a point value.
Mandatory Requirements
It was decided to retain a mandatory section for both Levels
II and III, which consists of the baseline foundations of
the advanced nurse. It includes the initial application
signed by the nurse manager in support of advancement
for the applicant. Additional requirements are a curriculum
vitae, recommendation letters, professional goals and
objectives for the upcoming year, committee participa-
tion at the unit or hospital level, additional continuing
education, attendance at a minimum of three Evidence
Based Practice and Research Council meetings, and an
annual performance evaluation from the applicant’s man-
ager. An additional requirement is the patient and family-
centered story. This is a clinical narrative that describes
how the nurse was affected by the patientYnurse relation-
ship and the impression left after caring for the patient.
Writing this narrative allows the nurse to highlight his
or her clinical practice in a format that can be shared with
coworkers (Owens & Cleaves, 2012). Finally, all applicants
are required to complete the initial institutional review
board training and renew the training every 3 years. Man-
datory requirements for Level III are the same with an
additional requirement of certification or Master’s degree,
additional contact hours, and membership in a profes-
sional nursing organization. The nurse must either renew
his or her advancement each year or, if at Level II, advance
to the next level.
Point System
As a part of the redesign, a point system was developed to
help provide the nurses with additional options to use toward
advancement. As previously stated, these sections were divid-
ed in accordance with the components of Magnet and A
placed activities that corresponded to the heading within each
group (see Table 1). The actual task of assigning points in
the categories was more challenging than originally
Journal for Nurses in Professional Development
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
thought. First, decisions were made regarding the overall
point requirement: 60 total points for Level II and 90 for
Level III. Each section had a minimal point requirement of
10 for Level II and 15 for Level III. The remainder of the re-
quired points could be obtained in the section that the nurse
chooses, thereby capitalizing on his or her strengths.
Incentive
One process that remained unchanged from the original pro-
gram was the financial incentive staff nurses received for
successfully completing the program requirements. Nurses
who have advanced are recognized for excellence in nursing
practice in several ways including an invitation to a luncheon
to highlight the applicant, a PNDP pin, and a framed certifi-
cate. A monetary bonus of 5% above base rate is awarded to
a Level II RN, and a 10% increase is awarded for Level III.
Submission
Initially, submission dates were four times per year, which
decreased to three times per year in 2009. After the first
year of the program, it was decided that the process would
be more streamlined by having two submissions a year
instead of three. The contents of the portfolio are placed
in a binder following the rubric in the manual. On the
day of submission, the portfolio must be turned in to the
CNE. Within 2 weeks, a review day is held, and the entire
committee participates. The portfolios are all reviewed
by at least two members of the committee for completeness
and accuracy and, subsequently, either approved or denied.
Appeal Process
In the event that a nurse’s portfolio and advancement is
denied and he/she feels that this decision is in error,
there is a structured appeals process in place. A separate
oversight committee is in place consisting of a nursing
director, nurse manager, assistant nurse manager, ANC,
PNDP Committee member, Nursing Congress member,
a Level III RN, and the Co-chair of the PNDP committee
(nonvoting member). The appeal must occur in writing
to the chairperson of the PNDP Committee requesting a
review of their portfolio within 14 days of denial notifi-
cation. The appeals process must be complete within
30 days of the committee decision. It is important to note
that the appeal may not contain any information that was
not submitted with the original portfolio as justification
for the appeal. The oversight committee may overturn
the denial only when there is clear and convincing evidence
that contradicts the original decision. The decision of the
PNDP oversight committee is final. Historically, there have
been very few denials in the program, as the members of the
PNDP committee are accessible by email or phone to assist in
the submission process. The goal of the committee is to en-
courage involvement and promote success in the program.
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TABLE 1 The Point System and Activities
Exemplary
Professional Practice
Years of experience
Peer evaluation
Clinical/quality experts
QI project
BSN or MSN degree
Enrolled in BSN or
MSN program
National certification
Clinical certification
NDNQI data collection
Note. Some activities fit into and are offered in more than one category. This is for the nurse to utilize that activity in the area he or she needs it most.
Abbreviations: CEU, continuing education unit; EBNP, evidence-based nursing practice; NDNQI; national database for nursing quality indicators; PICOT,
population, intervention, control, outcome, time; QI, quality improvement.
E4 www.jnpdonline.com
Transformational
Leadership
Shift leader
Preceptor
Attend preceptor class
Nursing congress member
Additional committee
involvement
PNDP mentor
Taskforce participation
Assist with nurse
residency program
Award or honor
Attending leadership
development workshops
Community involvement
Leadership/participation
in a professional nursing
organization
Manuscript reviewer
Certificate in healthcare
management
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Structural
Empowerment
Develop/present a unit
education
Design a storyboard
Oral presentation off your
home unit
Develop patient and family Develop and complete an evidenced-based
education materials practice project
Poster presentation
Oral presentation (outside
of UAB)
Journal club participation
Critique an EBNP article
and present to peers
CEU’s beyond mandatory
requirement
Resuscitation instructor
Assist with simulation
Certification
Community involvement
Enrolled in school
Volunteer at a UAB event
Completion of the geriatric
Scholar program
Completion and submission Attend an outside conference
of a CEU application
New Knowledge, Innovations,
and Improvements
Develop 3 PICOT questions
Conduct a literature review on one
PICOT question and summarize
Complete a critical appraisal of a
research article
Journal club participation
EBNP and Research Council:
Y Participation in a subcommittee;
present EBP article critique,
clinical issue, or PICOT question
EBNP council meeting attendance
EBNP Council Research Day:
Y volunteer
Y submit and abstract
Y present poster
Y oral presentation
Attend EBNP and research related
educational offerings
Develop EBP/QI/process improvement
or research education to staff
Research involvement
Attendance at congress
November/December 2016
Announcement and Education of Nursing Service TABLE 3 Numbers of Staff in the
Prior to the implementation of the new PNDP, there
needed to be a plan to disseminate all the information Revised Clinical Ladder Program
to the staff. Initially, the nurses currently in the program (Professional Nursing
were invited to take part in a question and answer session Development Program)
regarding the new program. It was hypothesized that, by
Professional Nursing
informing the current Level II and Level III nurses, they Development Program 2012 2013 2014 2015
could assist in mentorship and education of the program
Total Level II 78 91 106 95
to the nurses interested in advancing. The PNDP Committee
offered several information sessions that are convenient Total Level III 30 23 23 26
for both shifts and open to all nursing staff. The information
was presented to nursing leadership at the Nurse Manager
Council meeting and shared with directors. The changes though the decrease in submissions was anticipated with
were communicated to all ANCs. The new PNDP packet the start of the revised program, the number of submissions
materials were uploaded onto the hospital intranet site for and renewals for both Level II and Level III remained
the nurse to download and complete at their convenience. similar (see Table 3).

PNDP Workshops PNDP Survey Results

PNDP Workshops are scheduled throughout the year for
staff to receive information on the program. There are
‘‘PNDP Process’’ workshops available to guide applicants
on how to get started and successfully complete the port-
folio. Because of requests from staff, additional workshops
were added to accommodate both day and night shifts.
Each aspect of the portfolio was reviewed, and example
portfolios were available to show staff how to assemble
the information. Twice a year during the submission
months, there are ‘‘PNDP Review’’ workshops for nurses
that intend to submit a completed portfolio. Members of
the review committee are present to review the portfolio
for order and accuracy and to verify that the point require-
ments are adequately met. This process is beneficial in
helping to ensure successful completion of the program.
Currently, all communication is through the hospital intra-
net, which is updated with current information regarding
submission, workshop dates and locations, and contact
information for all committee members.
EVALUATION OF THE CAP
Participation
The original CAP began in December of 2004, and Level II
submissions steadily increased in the number through
2011. The number of Level III submissions also grew but
remained in low numbers overall (see Table 2). Even
In 2014, an online survey was developed by the CNE and
administered to the nursing staff to explore outcomes of the
PNDP program. A total of 162 nurses responded with the
majority being Level II nurses (see Table 4). The survey
results were overwhelmingly positive with most nurses
reporting that the CAP led to improved employee satis-
faction, influenced retention, and helped them grow
professionally (see Table 5).
DISCUSSION
CAP Development and Revision
This article is one of a limited number in the literature that
outlines the steps of implementing and redesigning a Clin-
ical Ladder Program. Although the numbers are relatively
low for a large academic hospital, the results are positive
for nurses who participate. The revision of the original pro-
gram was a challenging and exciting task, which was a
collaborative effort of many representatives in the nursing
profession. It has evolved over the years into a program
showcasing professional nursing practice and continues
to do so. It is noted that Clinical Ladder Programs can pos-
itively impact nurses’ sense of contribution to the
organization and at the same time enhance professional
skills (Fusilero et al., 2008). It is also important to track out-
come data in order to substantiate the value of a Clinical
Ladder Program (Winslow et al., 2011). This program

TABLE 2 Numbers of Staff Nurses in the Old Clinical Ladder Program

(Clinical Advancement Program)
Clinical Advancement Program 2004 2005 2006 2007 2008 2009 2010 2011
Total Level II 15 20 78 98 100 99 114 129

Total Level III 0 3 15 24 24 26 27 23

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TABLE 4 Survey Respondents (N = 162)
Respondent n Percentage
Active in PNDP Y Level II 70 43.21%
Active in PNDP Y Level III 22 13.58%
Currently working on PNDP 37 22.84%
Formerly active in PNDP (job promotion) 16 9.88%
Formerly active in PNDP (school) 5 3.09%
Formerly active in PNDP (other reason) 12 7.41%
Note. PNDP = Professional Nursing Development Program.
showed positive results in retention and satisfaction of
nurses along with helping them to grow and provide learn-
ing opportunities. These outcomes are tracked and
assessed on a continuous basis.
The revision to the point system has been successful in
that nurses have more options to challenge themselves.
However, in the redesign, the evidence-based practice or
quality improvement project became optional. This change
led to almost no one completing a project. The committee
will need to rethink this decision for the future.
Lessons Learned
One of the most important lessons learned is to enlist
strong senior leadership support for the program. In the
early years, the CAP was not assigned to a designated de-
partment; however, in 2009, with the evolution of the
CNE, the program began to have a stronger leadership
commitment. A next step is to assign this program to an
advanced nurse educator (NPD practitioner) who will
have dedicated time to grow and sustain the program.
One of the most important lessons learned is that time
commitment to a program is essential for growth. Al-
though this staff nurse-led initiative has been successful,
the additional dedicated NPD practitioner will bring
much needed insight to expand the program. In addition,
a future initiative will be to develop a mentorship program
using current PNDP nurses to assist in the recruitment of
new applicants.
Another important lesson learned was not to be afraid
of change. Making small changes to the program is man-
ageable; redesigning a program is a challenging task.
There have been nurses who state that the CAP is too dif-
ficult, the monetary compens ation needs to be
increased, or they will not participate if they have to do
an evidence-based practice or quality improvement pro-
ject. The key is to design your program to meet the
current needs of your organization and hardwire it to be
successful. The NPD practitioner can assist staff in
hardwiring the process.
Challenges of the CAP
There continues to be ongoing challenges for our CAP.
One is the size of the nursing workforce at UAB. Even with
all the known benefits of the program, many nurses do not
take advantage of this professional growth opportunity.
The second challenge is a result of the creation of a
higher-level assistant nurse manager position. Although
the CAP helped to prepare many of these nurses to move
into a leadership position, the program lost many of the
Level III nurses because of the fact that only bedside nurses
are eligible.
CONCLUSION
It is important to continually assess the effectiveness of
Clinical Ladder Programs. Each year, improvements are
implemented to the process or to add activities that align
with the organizational goals. PNDP nurses have taken

TABLE 5 Survey Results (N = 162)

Strongly
PNDP Program Strongly Agree Agree Neutral Disagree Disagree
Helped me to grow professionally. 48.77% 38.27% 6.79% 3.09% 3.09%

Provided me with learning opportunities. 56.79% 34.57% 3.70% 2.47% 2.47%

Is a beneficial program for nurses who wish to grow 56.17% 32.10% 5.56% 3.09% 3.09%
professionally at UAB.

Positively impacted my employee satisfaction. 37.65% 37.65% 15.43% 4.32% 4.94%

Is a program that positively impacts retention of nurses. 34.57% 33.33% 19.14% 8.02% 4.94%

I am satisfied with the PNDP program. 38.27% 37.65% 9.88% 6.79% 7.41%
Note. UAB = University of Alabama at Birmingham; PNDP = Professional Nursing Development Program.

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on tasks and projects that enhance patient care along with
quality outcomes throughout the organization. Applicants
are involved in councils and committees and often be-
come leaders throughout the organization. In addition,
PNDP nurses have been involved in several key educational
initiatives such as teaching Magnet preparedness, catheter-
A novice to expert to enhancing outcomes. Journal of Continuing
associated urinary tract infection prevention education,
and teaching in RN and patient care technician orientation.
Moving forward, senior leadership has challenged the
PNDP Committee to implement a redesign of the existing
program. This challenge is related to the focus to keep staff
at the bedside. The nursing shortage in health care today
makes it ever more important to provide a mechanism for
more advanced practice nurses to remain at the bedside. Ev-
idence indicates that more highly educated nurses can equal
safe care and promote better patient outcomes, which in
turn make retention a crucial component in practice (Lacey
et al., 2007). Beginning in 2016, new challenges include de-
signing a five-tier ladder with significant changes offering
incentives to keep Master’s prepared staff at the bedside.
In addition, options are being explored to have an electronic
submission process, create a ladder for ambulatory nursing,
and develop a ladder for the patient care technician.
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