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Advances in Social Sciences Research Journal – Vol. 8, No. 8
Publication Date: August 25, 2021
DOI:10.14738/assrj.88.10715. Fardellone, C., Meyer, J., & Woolforde, L. (2021). RN Perception of a Staff-Driven Professional Development Program. Advances in
Social Sciences Research Journal, 8(8). 320-330.
Services for Science and Education – United Kingdom
RN Perception of a Staff-Driven Professional Development
Program
Christine Fardellone, DNP, RN
Center for Tobacco Control, Northwell Health, USA
Jennifer Meyer, MSN, AGACNP
North Shore University Hospital, Northwell Health, USA
Launette Woolforde, EdD, DNP, RN-BC
Manhattan Campus, Northwell Health, USA
ABSTRACT
Nurses who participate in the clinical ladder professional development program
have an opportunity to grow at the bedside, gain experience, and improve in the
care they provide to their patients. Learning more about the clinical ladder
members and how to attract additional members is necessary. The clinical ladder
program was developed to promote personal growth and professional development
of bedside nurses. Clinical ladder programs have become increasingly well known
for the ability to promote job satisfaction, improve employee engagement, and
strengthen the quality of nursing care. The theoretical framework of the clinical
ladder program is based on Patricia Benner’s Model, “Novice to Expert”. This study
will evaluate registered nurses’ perceptions of the effectiveness of the clinical
ladder program and the importance of financial compensation. Effectiveness of the
program is defined as providing an environment that recognizes clinical excellence
and enables nurses to grow in their clinical ability. A convenience sample of 341
staff clinical ladder nurses employed in the Northwell Health System responded to
the demographic questionnaire and the Clinical Ladder Assessment Tool survey.
The data from the subjective responses were analyzed. Clinical ladder nurses
scored 32/36 (89%) responses as positive. Overall, the program was effectively
orchestrated. More than 50% of the nurses scored financial compensation as
greatest importance. Statistical significance was reported in the perceived
effectiveness of the clinical ladder program based on ladder level. The clinical
ladder program continues to empower nurses to participate in professional and
self-development. The clinical ladder program provides opportunities for
collaborating, mentoring, developing new knowledge, engaging in the decision- making process, and acting as advocates and leaders for patient care. Organizations
who continue to support professional development of bedside nurses will
experience innovations which influence all levels of the health care system.
Key Words: Professional development programs, Clinical ladder programs, Clinical
Ladder Assessment Tool
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Fardellone, C., Meyer, J., & Woolforde, L. (2021). RN Perception of a Staff-Driven Professional Development Program. Advances in Social Sciences
Research Journal, 8(8). 320-330.
URL: http://dx.doi.org/10.14738/assrj.88.10715
INTRODUCTION
Northwell Health’s mission statement discusses the dedication to improving the health of the
communities it serves as well as its commitment to providing the highest quality clinical care
while educating the current and future generations of health care professionals. Additionally,
the mission fosters a culture of quality, research, education, operational performance, service
excellence, workforce development, and community health advocacy. Northwell Health also
uses a patient and family centered care model to provide the highest standard of care. The staff
at North Shore University Hospital, the largest hospital in Northwell Health, works to closely
align their professional goals with this mission.[1]
The clinical ladder program was developed by the Northwell Health system nursing leadership
and rolled out at North Shore University Hospital to promote personal growth and professional
development to bedside nurses. “Clinical ladders provide a framework for professional nursing
development and have shown increased personal and professional satisfaction.”[2] The clinical
ladder program provides an opportunity for nurses to grow in their clinical expertise and gain
leadership experience while remaining at the bedside.[1,3]
The clinical ladder program requires nurses to submit yearly professional portfolios outlining
their accomplishments and activities. All components of the annual portfolio must reflect
relevant, up to date activities that occurred or were sustained over the last calendar year. A
points system assigns a value to each activity. Examples of activities include continuing
education, staff education, presentations, and committee memberships. In order to be
designated as a clinical ladder nurse, he or she must accrue 150 points for level I, 225 points for
level II, and 300 points for level III. With each level the nurse is awarded a pay differential.[1]
The goal of this research is to identify the effectiveness of a professional development program
by registered nurses enrolled in a clinical ladder career pathway.
LITERATURE REVIEW
The conception of the clinical ladder program was introduced in 1972 by Marie Zimmer who
served as the Director of Nursing Services at University of Wisconsin Hospitals and Associate
Clinical Professor at University of Wisconsin School of Nursing in Madison. Zimmer presented
the first clinical advancement program to recognize nurses.[4]
Clinical ladder programs were designed to advocate and incentivize professional development
among frontline staff nurses. This is accomplished while strengthening the quality of nursing
practice and enhancing nurse retention and performance in the workplace. [5,4] The clinical
ladder program strives to benefit all involved, from the staff, to the patient, to the hospital.
Clinical ladder programs have become increasingly well known for the ability to promote job
satisfaction and professional development, as well as improve employee engagement. [6-9]
Catholic Medical Center in Manchester New Hampshire reported clinical ladder nurses
participating in professional development, certification, education, committee work, and
increased confidence and engagement to meet the organization’s strategic goals.[10] Through
the widespread use of clinical ladder programs in hospitals, it has become evident that the
programs are an integral component to a facility’s recruitment and retention of professional
nurses. Clinical ladder programs strengthen the quality of nursing care.[5]
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The numerous research studies that evaluated clinical ladder programs report copious benefits
in adopting and implementing the programs. In 2005, Drenkard and Swartwout’s [11] research
found that hospitals offering clinical ladder programs had more satisfied staff than facilities that
do not offer opportunities for advancement. Health care organizations must remain
competitive and promote professional development of the direct care work force. Clinical
ladder nurses are expert nurses who demonstrate increased satisfaction with employment.
Nurses participating in the ladder program are often promoted to advanced leadership
positions, education, and clinical specialty. The goal of the clinical ladder program is to advance
clinical skills to expert level through education and professional development. Clinical ladder
programs are a sustainable model for clinical staff nurses in their career advancement.[11,12]
The underlying themes in many of the research studies include job satisfaction, nurse retention,
and benefits of implementing or revising a clinical ladder program. [7,13,14] In a systematic
review of job satisfaction conducted by Lu, Barriball, Zhang and While [15] it was reported that
autonomy as well as recognition by peers and administration are closely associated with job
satisfaction. Verbal, written, and financial rewards were also gauged positively. One of the
common outcomes frequently identified in the literature is the clinical ladder program “creates
salary levels for staff nurses in clinical practice commensurate with greater job demands and
associated increases in personal effort.” [16] When examining the benefits associated with
clinical ladder programs, Bjørk, Hansen, Samdel, Torstad, and Hamilton [13] concluded that
clinical ladder nurses were more aligned with the hospitals’ mission statement than those
nurses who were not on the ladder. Among clinical ladder nurses, recognition by peers and
management as they advanced up the ladder, as well as opportunities for professional growth
were factors that were valued.[8]
Theoretical Framework
The theoretical framework of clinical ladder programs is based on Patricia Benner’s Model,
“Novice-to-Expert”. The five stages of professional growth in nursing include novice, advanced
beginner, competent, proficient, and expert. Nurses in the novice stage of professional
development are new to the nursing profession and may have minimal skills performing tasks.
Advanced beginners utilize knowledge from experience but may require coaching during
challenging situations. Competent nurses demonstrate the ability to address problems with
abstract, conscious, and analytical thought. They usually have 2 to 3 years of experience
working in similar situations. Proficient nurses accurately make decisions, diagnose, and
handle problems at hand. They perceive situations holistically instead of fragmented pieces.
Expert nurses solve problems with precision. They are highly skilled and motivated to cope
with new and challenging situations.[17,18]
In 1999, the literature review on the utilization of clinical ladder programs found Benner’s
theoretical framework, to be the most frequently cited model for clinical ladder programs.[19]
This model focuses on clinical experience, educational background, and competencies as
criteria for advancement. Recent literature supports the evidence that the Benner Model
continues to serve as the theoretical framework in the implementation of clinical ladder
programs in hospitals. [20,7-9,14] The professional development committees at HCA Virginia
Health System and Vanderbilt University have implemented the Benner model as the
theoretical framework in their clinical ladder programs in addition to multiple health systems,
and hospitals.[21,22]
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Fardellone, C., Meyer, J., & Woolforde, L. (2021). RN Perception of a Staff-Driven Professional Development Program. Advances in Social Sciences
Research Journal, 8(8). 320-330.
URL: http://dx.doi.org/10.14738/assrj.88.10715
Staff-Driven Professional Development Program
The clinical ladder program at North Shore University Hospital has grown substantially in
recent years. At the end of 2013, there were 102 registered nurses on the ladder. This number
had remained flat since the program’s inception. A new campaign was launched to reinvent the
clinical ladder program to become staff-driven and encourage engagement and activity within
it. The portfolio review process was restructured to form a committee with a peer review
process. Thus, communication increased between the clinical ladder co-chairs, the clinical
ladder review board members, and clinical ladder nurses. A grass-roots campaign, guided by
the co-chairs and review board, aimed to diversify the professional development activities of
the nurses and introduce the program to those who were unfamiliar with it. Nurse educators
began to include clinical ladder nurses as peer teachers and new recognition efforts were
implemented. The clinical ladder program was identified as a key source for succession
planning. Between 2013 and 2020 membership in the clinical ladder program grew over 300%
from 102 to approximately 361 registered nurses. Clinical ladder nurses began volunteering at
health screenings, co-teaching in the rollout of the education related to new equipment, as well
as required offerings such as basic life support (BLS) and advanced cardiovascular life support
(ACLS) co-instructors. Clinical ladder nurses began participating in research studies, serving as
validators at annual skills fairs, participating heavily in the hospital wide employee flu
vaccination program and recognizing and rewarding clinical ladder members with a
congratulatory letter and a clinical ladder pin.
The staff-driven program meets monthly to review clinical ladder portfolios and precept
potential new members. The clinical ladder review board members produce a quarterly
newsletter which is distributed to all members, nurse managers, and displayed for other staff
to gain knowledge about professional development opportunities. The members participate in
fundraisers which support Northwell Health and community advocacy. The clinical ladder staff
provides presentations for the collaborative care council and the chief nursing officer council.
This forum provides an opportunity for the nurses to share the activities that are occurring at
the staff level. The nurses promote continuing education webinars and journal clubs and
mentor members of the inter-disciplinary team. The clinical ladder nurses are leaders for
patient care and professional development of the nursing profession. The staff-led clinical
ladder is an important program that fosters professional development, engagement, and
succession planning among bedside registered nurses. It was designed to support the
Northwell Health philosophy of nursing practice through the creation of a career advancement
track for the clinical nurse. [11,3]
Significance for Nursing
Still, despite the incentives both monetarily and professionally that the program provides, 361
registered nurses is a fraction of the total nurses at North Shore University Hospital who could
potentially participate in the clinical ladder program. The total number of clinical ladder nurses
has changed due to numerous advancements to mid-level provider and management roles
making them no longer eligible for the program. Also, within the program there are nurses that
are highly involved and motivated and others who are less active. This study addresses the lack
of information in the literature about the effectiveness of the clinical ladder program. Learning
more about the clinical ladder members and how to attract additional members is necessary.
The significance of this study will evaluate registered nurses’ perceptions of the effectiveness
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of the clinical ladder program and the relationship between the importance of financial
compensation and the perception of the effectiveness of the clinical ladder program.
Effectiveness of the program is defined as providing an environment that recognizes clinical
excellence and enables nurses to grow in clinical ability. The specific question of financial gain
with participation in the clinical ladder program arose due to direct observation of financial
inquiries from the staff.
METHOD
A descriptive, correlational, cross sectional study design was used as the research method to
survey one sample group of clinical ladder nurses during a 1-month time period. The study
setting was a large tertiary care medical center, North Shore University Hospital located in the
north-eastern region of the United States. This medical center is part of the region’s largest
health system. The survey was electronically distributed to a convenience sample of clinical
ladder nurses. Inclusion criterion is current appointment to the clinical ladder program and
active employment at North Shore University Hospital. Exclusion criteria include registered
nurses not currently participating in the clinical ladder program. A self-report electronic survey
was distributed to all clinical ladder nurses via their work email. All members have access to
the hospital email. This email described the purpose of the study, the questionnaire, and the
consent for participation. The data was collected via REDCap. Only the researchers had access
to the study findings.
Instruments
The instrument used in this study was an electronic self-report survey, the Clinical Ladder
Assessment Tool. Demographic data included, age, highest level of education, years of
experience as a registered nurse, clinical ladder level, certification, and current specialty unit.
The Clinical Ladder Assessment Tool is a 36-item questionnaire with 7 sub-scales that measure
the effectiveness of the clinical ladder program. The tool has a Cronbach’s Alpha score of 0.95.
Participants respond ‘yes’ or ‘no’ to each item. The Clinical Ladder Assessment Tool was
administered using the REDCap program. Permission to utilize the survey was granted by Sarah
Strzelecki Ed.D, MBA, RN of Phoenixville Hospital.[23]
Statistical Analysis
Descriptive statistics and measures of central tendency and dispersion were calculated to
answer the demographic data and the following research questions:
RQ 1: What is the self-perceived effectiveness of the clinical ladder program?
RQ 3: What is the relationship between the importance of financial compensation and the
perception of effectiveness (self-report) of the clinical ladder program?
The Chi Square Test of Association was used to evaluate RQ 2: Are there differences in the
perceived effectiveness of the clinical ladder program based on clinical ladder level?
Protection of Human Subjects
This study received Northwell Institutional approval and IRB approval from the Feinstein
Institutes for Medical Research before data collection began. The benefit of participating in the
study was to gain knowledge about the effectiveness of the clinical ladder program and
disseminate the findings. The participants were informed in writing that they may voluntarily
participate and they may stop participating at any time. Participation had no effect on their
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Fardellone, C., Meyer, J., & Woolforde, L. (2021). RN Perception of a Staff-Driven Professional Development Program. Advances in Social Sciences
Research Journal, 8(8). 320-330.
URL: http://dx.doi.org/10.14738/assrj.88.10715
status as a clinical ladder nurse. Confidentiality was maintained on all responses. There were
no known risks for participating in the study.
RESULTS
Of the 341 clinical ladder registered nurses 104(30%) completed the demographic
questionnaire and the Clinical Ladder Assessment Tool survey. The age range was 21 to >50
with a mean of 40 years. Of the sample 79(76%) hold specialty certification. The clinical ladder
levels are reported as level I (n=13, 13%), level II (n=19, 19%) and level III (n=72, 68%). In
addition, the sample reported BSN (n=61, 59%), Bachelors enrolled in Masters (n=20, 19%),
Masters (n=22, 21%), and Doctorate (n=1, 1%).
The Clinical Ladder Assessment Tool includes 7 subscales: differentiation of levels of nursing
competencies, guide for evaluation of clinical performance, assures opportunities for
professional growth, reinforcement of responsibility and accountability in nursing practice,
rewards and benefits are commensurate with levels of practice, job satisfaction through
recognition for clinical practice, and provides for increased levels of autonomy and decision
making. Each subscale contains sub-components evaluating the topic.[23]
The majority of the registered nurses participating in the study responded yes to all sub- components of 5 subscales: guide for evaluation of clinical performance, assures opportunities
for professional growth, reinforcement of responsibility and accountability in nursing practice,
rewards and benefits are commensurate with levels of practice, and provides for increased
levels of autonomy and decision making.
The majority of registered nurses responded yes to 6 of the 7 sub-components of differentiation
of levels of nursing competencies and 1 of the 4 sub-components of job satisfaction through
recognition for clinical practice. Overall, the program was effectively orchestrated with 32/36
(89%) responses rated as positive.
Table 1 summarizes the Clinical Ladder Assessment Tool subscale results. Statistical
significance or weak association was reported in 5 areas: differentiation of levels of nursing
competencies, assures opportunities for professional growth, rewards and benefits are
commensurate with levels of practice, job satisfaction through recognition for clinical practice,
and provides for increased levels of autonomy and decision making. The data from the clinical
ladder level and the sub-component statements are recorded.
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Table 1. Clinical Ladder Level
Clinical Ladder CLI CLII CLIII p
value
Assessment Tool YES NO YES NO YES NO
I know exactly what I
need to do in order to
advance on CLP.
11 (85%) 2
(15%)
13
(68%) 6 (32%) 66
(96%) 3 (4%) 0.003
I believe that the CLP
provides adequate
opportunity for
promotion while I
remain in clinical
practice.
13(100%) 0
(0%)
14
(74%) 5 (26%) 48
(70%)
21
(30%) 0.07
I know the rewards and
benefits related to each
step in the clinical
ladder.
12 (92%) 1 (8%) 13
(68%) 6 (32%) 62
(90%)
7
(10%) 0.045
For me, advancement in
the CLP provides a
sense of
accomplishment and
professional
satisfaction about my
work and choice of a
career.
12 (92%) 1 (8%) 13
(68%) 6 (32%) 66
(96%) 3 (4%) 0.002
Advancement in the
clinical ladder
encourages me to
utilize an increased
knowledge base and
sophisticated nursing
skills.
12 (92%) 1 (8%) 11
(58%) 8 (42%) 53
(77%)
16
(23%) 0.075
Table 2 summarizes the importance of financial compensation and the perception of the
effectiveness of the clinical ladder program. Financial compensation was scored 1-5 (least
importance to greatest importance). Less than 5% of the nurses scored less than 3 for financial
importance. More than 50% of the nurses sored financial compensation as greatest importance.
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nurses are satisfied with the rewards and benefits associated with advancement in the clinical
ladder. The sub-component 5.3[23] reports 76 percent of the nurses believe that the
differentiation of the rewards and benefits incentives for advancing in the clinical ladder are
fair and equitable.
There were statistical significances reported according to the clinical ladder level. As nurses
advance up the ladder, gain experience, and have increased levels of autonomy and decision
making, they may experience improved self-esteem, engagement, and professional satisfaction.
The data from sub-component 1.1[23] reported 57 percent of the nurses responding that the
clinical ladder expectations were not reviewed at my orientation so that I clearly understood
what was expected of me. Although, the demographic data reported 91 percent of the nurses
did receive information at North Shore University Hospital on how to apply for the clinical
ladder program. This finding was addressed as an issue that needs improvement. This result
was reported to the nursing education department and the clinical ladder review board
developed a flyer for nurse managers to provide to staff nurses who are eligible to participate
in the clinical ladder program.
CONCLUSION
Nurses who participate in the clinical ladder professional development program have an
opportunity to grow at the bedside, gain experience, and improve the care they provide to their
patients. The nurses also may experience improved job satisfaction, clinical performance, and
strategies for retention and promotion. The staff-driven program provides opportunities for
professional and self-growth as well as collaborating, mentoring, developing new knowledge,
engaging in the decision-making process, and acting as advocates and leaders for patient care.
The effectiveness of the clinical ladder program described in this study will continue to
empower nurses to support their peers and participate in professional development which may
improve patient and health care outcomes. Nursing leadership and health care organizations
who continue to support professional development programs may experience innovations
which influence all levels of the health care system. [24]