Applicants to the Clinical Ladder must meet the following minimum qualifications:

1. Transferred within the last 3 months, a recommendation from manager on the unit where most recently worked.
2. Minimum one year of experience as a licensed Nurse at St. Elizabeth.
   1. Applicants with a MINIMUM of one year of experience and a MAXIMUM of two years of experience are required to apply for a CN I.
   2. Experienced nurse (>2 years of experience as an RN) new hire to the organization or transfer to a specialty area can apply for clinical ladder after one-year experience on hired unit. Once the applicant has one-year of nursing experience in new area the applicant can achieve a CN II, CN III, or CN IV (not eligible for a CN I).
   3. Clinical Nurses with greater than 2 years of experience are eligible to apply for a CN II, CN III, or a CN IV. Experienced nurses may start at CN II and/or climb the ladder to a CN III. First time applicants will need to achieve a CN III before they are eligible for CN IV.
3. At least twelve months between applicants’ last Clinical Ladder enrollment.
4. Current performance management rating of Meets Expectations.
5. No current formal discipline of Level II or higher or under any current regulatory restriction.
6. Provides direct patient care at the bedside.
7. CN III requires either a BSN or National Certification in specialty area (Effective 1/2011). CN III also requires an EBP review or Research Proposal (Effective 1/2019)
8. CN IV requires BSN and National Certification in specialty area. CN IV requirements: Primary Investigator or Co-Investigator of a Research Study, EBP Change Project (unit or system), or Nursing Research/EBP Presentation: National.  

Program Overview

The clinical ladder is based on Patricia Benner’s Novice to Expert Theory. The theory describes the development of the nurse from the novice to the expert stage. As a nurse advances through his/her career, they continue to develop professionally with a never-ending acquisition of new knowledge and skills. As a new graduate, the nurse is a novice, and as he/she develops professionally and gains experience and knowledge, will go through different stages of development: advanced beginner to competent, competent to proficient and ultimately proficient to expert.

Nursing performance will change as the nurse acquires new knowledge and skills. The nurse will move from a reliance on principles and rules to the use of past, concrete experience to make nursing decisions. This results in a shift from reliance on analytical, rule-based thinking to reliance on intuition. The nurse’s perception of the situation changes from viewing it as a compilation of equally relevant parts to viewing the situation as an increasing complex whole in which certain parts stand out as more or less relevant. The nurse moves from a detached observer, from standing outside the situation, to one of a position of involvement fully engaged in the situation.

The theory has seven domains to describe the competencies (behaviors) within nursing practice. The seven domains are: (1) The Helping Role; (2) The Teaching-Coaching Function; (3) The Diagnostic and Patient/Monitoring Function; (4) Effective Management of Rapidly Changing Situations; (5) Administering and Monitoring Therapeutic Interventions and Regimens; (6) Monitoring and Ensuring the Quality of Health Care Practices; and (7) Organizational Work-Role Competencies. The domains represent behaviors to demonstrate and measure professional growth, new knowledge and skill development/acquisition and innovation in nursing practice.

The clinical ladder identifies three categories to organize nursing behaviors representative of Benner’s seven domains. The categories are Professional Development, Leadership and Clinical Expertise. These behaviors assist the nurse in his/her ongoing professional growth by developing knowledge, and skills to move through the Clinical Ladder levels. This ongoing professional growth demonstrates Benner’s stages of development, beginning at the competency nurse stage to expert nurse stage.

Clinical Nurse Definitions

Clinical Nurse CN I

The new graduate RN one year of experience (within the hospital or on a specialty unit) is recognized as a novice or advanced beginner nurse. Upon one year of nursing experience, the nurse is expected to achieve a competent level of nursing practice and developed behaviors consistent with professional nursing practice. Competency is demonstrated by a “meets expectation” performance appraisal.

Clinical Nurse CN II (Competent Nurse)

The CN II’s behaviors are conscious and deliberate in their planning of care and use efficiency and organization to implement the plan. The plan is based on abstract analytic contemplation of a problem by applying experiences and judgment in assessing the importance of various patient situations. The nurse is able to identify and set priorities for long-term goals within the plan. The nurse has a feeling of mastery and able to cope/manage with the many contingencies that can occur while implementing a plan. This level requires formal and/or informal education to stay current in practice issues and to continually increase their knowledge base.

Clinical Nurse CN III (Proficient Nurse)

The CN III’s behaviors are based on past experiences on how to respond to important aspects of a situation.

The behavior is guided by a principle (rule, guideline) to influence nursing practice. There is improved decision making due to a more holistic view of patient care/situations/events. Situations are perceived in terms of goals. The nurse views the patient as a whole being, rather than a diagnosis or set of problems. Intuitive thinking increases with experience. The CN III is able to act as a mentor, teacher or supervisor. This level requires formal and or informal education to stay current on practice issues and increase knowledge base.

Clinical Nurse CN IV (Expert Nurse)

The CN IV’s behavior is to understand the total situation and not just a holistic view. This behavior is guided by intuitive grasp of a situation and narrows in on the situation/problem with the accurate diagnosis and intervention. High critical thinking and analytical skills are necessary to be able to problem solve. These behaviors lead to leadership, resource person and educator roles. Unlike the other three levels, the CN IV does not need to rely on a principle to understand a situation and the appropriate nursing intervention to implement. The CN IV has the highest level of clinical expertise from experience and formal education.

Enrollment Period

Clinical Ladder applications are accepted twice per year, on April 15th and October 15th. Nurses must reapply yearly to maintain their status in the program. The program will be reviewed annually by the Clinical Ladder Committee, and revisions will be made as needed. Each year, the newly revised program will be available starting on October 16th. Applicants must use the most current version of the program when submitting an application. For example, a nurse who is applying for Clinical Ladder in April of 2022 must use the 2022 Clinical Ladder Application. Content can be transferred from the previous year’s application. Applicants are encouraged to reach out to their assigned mentor for assistance if unable to submit for the current year’s program.

Point System

The program is a point-based system. The behaviors/activities are organized into categories from which to gain points: Clinical Expertise, Professional Development, and Leadership. The category activities guide the nurse in his/her ongoing professional growth by developing knowledge, experience, and skills to move through the Clinical Ladder levels. This ongoing growth demonstrates Benner’s stages of development, beginning at the competency nurse stage to expert nurse stage. Each category contains measurable criteria from which to choose. A different point value is associated with each measurable criterion.