Nursing Advancement Before the Clinical Ladder

When I took my first job as a hospital staff nurse, pretty much the only path to advancement in the clinical setting was moving into an administrative position. Nurses moved up by becoming nurse managers, then supervisors, and eventually nursing directors. It was considered unusual for someone to stay at the bedside for many years.

Benner’s Novice-to-Expert Model

Then along came the clinical ladder—a way for nurses to advance clinically. Patricia Benner’s landmark work on identifying the hallmarks of novice-to-expert practice laid the foundation for identifying the different stages of acquisition of skills (see her article on the topic published in AJN in 1982; free until May 22).

Evolving Competencies Require New Paths to Advancement

But while the competencies nurses need to practice effectively are vastly different today, many hospitals haven’t updated their clinical advancement programs to reflect the knowledge, skills, and attitudes (KSAs) that nurses need to practice effectively in today’s complex health systems. Moreover, there’s been little research to provide the evidence for identifying the various competencies and the associated KSAs. Our original research article in the May issue provides that evidence.

Creating an Evidence-Based Progression

The authors of “Creating an Evidence-Based Progression for Clinical Advancement Programs” used the Delphi technique to identify 186 KSAs associated with eight competencies identified by the Institute of Medicine (now the Health and Medicine Division of the National Academies of Science, Engineering, and Medicine) and the Quality and Safety Education for Nurses (QSEN) initiative. They stratified and matched the KSAs to four practice levels, from a novice Clinical Nurse I to an experienced Clinical Nurse IV level.

In addition to providing a research base for advancement, these competencies are useful for delineating position descriptions as well as performance evaluations. The authors note:

“The findings may be used to inform position descriptions, hiring interview questions, performance appraisals, learning needs assessments, residency programs, orientation programs, ongoing competency assessment programs, and preceptor programs. As such, they can help promote a culture of high-quality care and safety.”

Read the article for free; you can also listen to a podcast interview with the authors.