Clinical Ladder

Clinical Ladder Breakfast Group

Nurses have always known that there are differences in levels of nursing expertise. The ability to recognize and reward those demonstrating clinical excellence is important. Historically, professional development programs were instituted to retain registered nurses by rewarding and recognizing nurses who practice at the bedside. The Professional Clinical Ladder Program strives to acknowledge qualities of excellence in clinical practice. The standards are based on the ANA Standards of Professional Practice and the PA State Board of Nursing.

Through self-assessment, direct-care nurses develop a portfolio that demonstrates their level of practice. The included subjective and objective data are evaluated by the peer led committee. The application process consists of three integrated components: application portfolio, audit, and interview. All three components are interrelated and complement each other to present a picture of the whole practice.

Eligibility Criteria

  • FTE of .5 or greater
  • Staff RN's in direct patient care positions
  • RN successfully passed probation and completed orientation
  • Minimum of 2 years nursing experience

Domains of Practice

Promotion on the Professional Clinical Ladder is based on the demonstration of clinical expertise in the following domains:

  • Domain 1: The Caring Role
  • Domain 2: Patient and Family Education
  • Domain 3: Clinical Practice
  • Domain 4: Monitoring and Ensuring the Quality of Health-Care Practices
  • Domain 5: Professional Collaboration and Consultation
  • Domain 6: Clinical Knowledge Development

Click here for Domain descriptions.

Description of Levels

  • Nurse Clinician I:
    The Nurse Clinician I is guided by policies, procedures and standards. The graduate nurse at this level is building a knowledge base through practice and is more comfortable in a task-oriented environment. The GN often describes a clinical situation from the viewpoint of what they need to do, rather than relating the context of the situation to how the patient responds. They continue to rely on the judgments of others. When complex clinical situations arise, they seek nurses with great authority. Experienced RNs entering the new employment situation have an existing foundation of knowledge and skills related to policies, procedures, and standards of practice. They seek resources to affirm that their recent practice is compatible with the Medical Center's practice. They can demonstrate critical thinking and decision-making skills. They can clearly articulate and document patient needs and interventions. All RNs enter the system as Level I. With successful completion of probation and orientation they proceed to a Level II.
  • Nurse Clinician II – Sound Practitioner:
    The Nurse Clinician II is fully competent. This nurse assumes responsibility for her/his primary patients. Deliberate planning, analysis, and goal setting are hallmarks of this nurse. This nurse recognizes relationships among patient data, and judgments made after careful consideration of this data. This nurse demonstrates mastery of most technical skills and focuses on organizational skills in their assigned clinical areas and is ready to learn the responsibilities of the charge nurse. Nurses then remain at Level II indefinitely and after six months are eligible to apply for Level III or IV.
  • Nurse Clinician III – Proficient Practitioner:
    Practices with an in-depth knowledge of nursing practice based upon previous experiences. A proficient nurse has progressed from a task-oriented approach to providing nursing care with a holistic view of the person. This nurse perceives each situation as a whole, and is able to identify the salient elements of those situations. Critical thinking is apparent and judgments are oriented toward the best possible outcome for the patient. This nurse responds to most situations with speed, confidence, and flexibility, and is able to handle unanticipated problems or emergencies. Effective relationships and leadership skills amount the multidisciplinary team are evident.
  • Nurse Clinician IV – Expert Practitioner:
    Intuition and skill arise from a comprehensive knowledge base thoroughly grounded in experience. Practice is characterized by a flexible, innovative, and confident self-directed approach to patient- and family-centered care. Rapidly changing and complex patient care situations challenge this nurse to reach her/his full potential. Ethical reasoning is evident. This nurse has a vision of what is possible, and a keen sense of timing to make things happen. The Nurse Clinician IV is system savvy, understands the interdependence of disciplines and departments, and can finesse situations to maximize patient outcomes. This nurse functions with an ongoing healthy skepticism, questioning situations that are atypical. The ability to automatically filter irrelevant data is evident. This nurse is a positive force in the advancement of professional practice and quality of patient care.