Karen T. Burwell, BSN, RN, CNN, is Clinical Manager, St. Joseph’s Hospital Dialysis Center, Syracuse, NY. She is Leader of ANNA’s Administration Special Interest Group and a member of the Central New York Chapter.

The American Nephrology Nurses’ Association (ANNA) Scope of Practice for general nephrology nursing states that the nephrology nurse participates in professional role development, which should include continuing education, participation in performance improvement activities, and participation in research (Burrows-Hudson & Prowant, 2005). A clinical ladder provides an objective measurement of achieving nursing autonomy and professional growth. The concept is based on the understanding that nurses practice at different levels of skills and competencies.

History of Clinical Ladders

The Revised Nephrology Nurses’ Clinical Ladder
The revised Nephrology Nurses’ Clinical Ladder behaviors are based on Patricia Benner’s novice to expert progression of nursing practice (Benner, 1984). The format and content are based on the 1989 ANNA Nephrology Nursing Clinical Ladder Program and the clinical ladder models from St Joseph’s Hospital Health Center, Syracuse, New York, Gambro Healthcare, and The University of Virginia, Professional Nursing Staff Organization. The revised Nephrology Nurses’ Clinical Ladder includes four levels that represent a progression of clinical skills, professional behaviors, expanded knowledge, and clinically focused educational activities in the hemodialysis setting.

Benner (1984) describes four general aspects of performance. Initially, new nurses rely on abstract principles and theoretical knowledge. Over time, they incorporate past concrete experience. The next shift moves the clinician from analytic/rule-based thinking to the use of intuition. As nurses move to the third level, they see the “whole picture,” but are able to identify that only certain parts are relevant. As they advance to the expert level, they become an active participant vs. a detached observer.
 
The new Nephrology Nurses’ Clinical Ladder incorporates five areas:

•  Clinical behaviors;
• Patient education;
• Leadership, team work, and collaboration;
• Communication; and
• Knowledge development and professional behaviors.

The progression of the nephrology nurses’ behaviors described in each of these categories follow Benner’s theory (see Table 1). The Nephrology Nurse 1 level is intended to only apply to new graduate nurses who should progress to the next level within 12 months. A registered nurse who has had previous experience would begin employment at the Nephrology Nurse 2 level (or higher) and should be able to meet the stated behaviors.

.	NN1	NN2	NN3	NN4
Clinical Behaviors	Demonstrates knowledge of principles and theories of dialysis. Consistently delivers safe and appropriate care. Consistently strives to improve dialysis skills. Begins to recognize the fundamentals of patient assessments, evaluates data and intervenes as appropriate. Evaluates patient’s response to nursing interventions. Assists with the development of nursing care plans. Begins to understand the actions, side effects and adverse reactions of medications and can intervene appropriately. Reports abnormal or unexpected findings to anemia or bone disease manager for evaluation and intervention. Demonstrates the ability to recognize emergencies and communicate findings to appropriate personnel. Accurately documents the components of the nursing process. Beginning awareness of outcomes with regard to patient care delivery	Demonstrates the ability to consistently and effectively apply principles and theories of dialysis to achieve desired outcomes. Understands the fundamentals of patient assessments, evaluates data and has the ability to establish appropriate plans to achieve desired goals. Has the ability to present data at patient care plan meetings. Understands the actions, side effects and adverse reactions of medications and can intervene appropriately. Begins to assist in the management of bone disease or anemia. Demonstrates the ability to cope with emergencies, and communicate findings to appropriate personnel. Accurately documents the components of the nursing process in a timely manner. Manages time effectively.	Demonstrates mastery of clinical skills and can consistently provide care to complex patients. Demonstrates advanced assessment skills. Plans individualized care in collaboration with the interdisciplinary team. Implements plan to achieve short and long term goals. Understands the actions, side effects and adverse reactions of medications and can intervene appropriately. Effectively serve as an anemia or bone disease manager. Demonstrates the ability to calmly and effectively deal with emergencies while acting as a leader and giving directions to others; communicates findings to appropriate personnel. Precisely documents the components of the nursing/problem solving process and relevant interventions. Communicates effectively to achieve outcomes in a timely manner. Seeks and implements improvement in patient outcomes.	Demonstrates mastery of clinical situations with comprehensive knowledge and experience and can consistently provide care to complex patients. Demonstrates a well developed expertise in assessment skills of patients. Plans individualized care in collaboration with the interdisciplinary team. Implements plan to achieve short and long term goals. Mentors other clinicians in the formulation of plans of care. Understands the actions, side effects and adverse reactions of medications and can intervene appropriately. Effectively serve as an anemia or bone disease manager. Mentors others in serving as anemia or bone disease managers. Demonstrates the ability to calmly and effectively deal with emergencies while acting as a leader and giving directions to others; communicates findings to appropriate personnel. Has the ability to modify the plan of care quickly and communicate findings to appropriate personnel. Promotes evidenced based practice. Demonstrates the ability to plan, develop, implement and evaluate unit protocols.
Patient Education	Recognizes the need for patient and family education on renal disease, dialysis prescriptions and medications. Involves patient and family in plan of care.	Assesses patient and family learning readiness. Includes patient and family in plan of care. Provides education to patients and family on renal disease, dialysis prescriptions and medications.	Assists patient and family to understand the relationship between disease process, prescribed treatment, medications and physicians’ orders with patients’ overall health and well being. Assists patient and family to actively participate in plan of care. Provides patient, family and staff education on renal disease. Coordinates clinical activities to effectively provide for patient education.	Anticipates patient and family needs and takes a leadership role in empowering patients and families in adapting to renal replacement therapy. Develops and delivers education programs to patients, family, staff and community on renal disease.
Leadership, Teamwork, Collaboration	Delegates appropriately. Utilizes interdisciplinary team as a resource in the development of individualized plans of care. Demonstrates an emerging awareness of the utilization of human and material resources.	Recognizes opportunities to improve patient outcomes and communicates to unit leadership. Effectively serves as a charge nurse or team leader. Manages time effectively. Utilizes human and material resources efficiently. Emerging awareness of Medicare regulations related to the ESRD program as they pertain to clinical activities.	Assumes a reliable leadership role in the unit. Demonstrates the ability to participate in a group to plan, implement and evaluate unit protocols. Effectively serves as a charge nurse or team leader. Orients others to the role. Demonstrates ability to lead patient care plan meetings. Assists with the evaluation of patient outcomes. Seeks ways to identify and improve patient outcomes. Assists others to manage time effectively. Provides supervision and guidance to others. Effectively serves as a charge nurse. Demonstrates the ability to manage the unit in the absence of the “Clinical Director”. Demonstrates knowledge of the financial impact of human and material resources. Seeks ways to increase productivity and decrease costs without adversely affecting patient outcomes. Has comprehensive knowledge of Medicare regulations related to the ESRD program	Demonstrates a self directed interdisciplinary leadership style. Assists in the evaluation of the charge nurse or team leader role effectiveness and updates the role description as warranted. Orients others to the role. Demonstrates ability to lead patient care plan meeting. Critically evaluates and initiates changes in the unit to improve patient outcomes. Assists others in the development of leadership roles in the unit. Role models professional practice. Partners with unit management and administration, assisting in the development of unit goals. Demonstrates the ability to manage the units in the absence of the “Clinical Director.” Evaluates and works to improve the process of patient care delivery with in the unit. Leads group initiatives to improve patient outcomes. Demonstrates knowledge of the financial impact of the utilization of human and material resources. Seeks ways to increase productivity and decrease costs without adversely affecting patient outcomes. Has comprehensive knowledge of Medicare regulations related to the ESRD program. Identifies and seeks resolution to issues not in compliance.
Communication	Demonstrates respectful and effective communication with patients, families and colleagues.	Communicates clearly and effectively, orally and in writing. Identifies barriers to communication and seeks resolution. Identifies and resolves conflict with assistance	Communicates clearly and effectively, orally and in writing. Demonstrates effective listening skills. Readily adjusts communication style and integrates differences to strengthen the team. Demonstrates proficient and timely conflict management skills, working to resolve unit concerns.	Communicates clearly and effectively, orally and in writing. Demonstrates and role models exemplary communication skills. Facilitates effective communication among individuals and in groups. Demonstrates proficient and timely conflict management skills, working to resolve unit concerns.
Knowledge Development and Professional Behaviors	Consistently solicits assistance and feedback regarding patient and practice setting issues. Accepts personal accountability for expanding knowledge of nephrology nursing and related skills. Has emerging awareness of ANNA as professional organization.	Works effectively as a member of the interdisciplinary team. Consults appropriately to interdisciplinary peers. Accepts personal accountability of professional development. Evaluates the effectiveness of their delegation. Actively participates in practice setting management (quality initiatives, committees, etc.). Familiar with standards of care and practice of the ANNA	Actively participates in interdisciplinary team, leading initiatives to improve patient outcomes. Accepts accountability for the professional development of self and peers through formal and informal staff education. Routinely utilizes and shares information from the ANNA. Certified in Nephrology Nursing.	Actively provides leadership of interdisciplinary team for resolution of unit specific issues. Actively evaluates own practice utilizing feedback from others. Identifies, initiates and collaborates to provide needed educational program. Actively involved in ANNA at local, regional or national level. Utilizes and shares information from professional membership participation with others. Certified in Nephrology Nursing.

Successful Clinical Ladder Programs
The individual nurse, the facility as a whole, and the nurse’s supervisor all have roles to play in the success of a clinical ladder program. What is pivotal about clinical ladders is that it is optional for nurses to move up the ladder with their professional growth driving the process. The facility incorporating a clinical ladder in their program can outline the process for advancement to meet the needs of the facility. Nurses applying for advancement should be able to articulate how they meet the behavior criteria, and advancement requires the support of their supervisors. The University of Virginia Health System requires the candidates to develop a portfolio to demonstrate that the nurse meets the behaviors of the level they are seeking. The portfolios include a curriculum vitae, self-evaluation, peer reviews, a letter of support from their manager, a recent performance appraisal, and clinical exemplars (Kauffman, Glassberg, Charlebois, & Curtis, 2006).

The Financial Impact
A candidate who successfully applies for advancement on the clinical ladder and is promoted typically receives an increase in salary. In today’s struggle to meet the rising costs of providing health care, it may be difficult to financially justify a clinical ladder; however, the use of clinical ladders in hospitals has revealed that there is a decrease in costs associated with clinical ladders, a decreased use of sick time by nurses, and higher nurse satisfaction (Drenkard & Swartwout, 2005). The Inova Health System in Falls Church, Virginia evaluated their “ADVANCE” (Achievements Demonstrating Versatile Accomplishments of Nursing Clinical Excellence) Nursing Clinical Ladder Program. Two years after implementing the clinical ladder, Inova saw an 8.9% reduction in nursing staff turnover (Drenkard & Swartwout, 2005). Inova analyzed the financial impact of turnover and concluded that a salary increase associated with a promotion on the clinical ladder was significantly less costly than recruiting, hiring, and training new nurses (Drenkard & Swartwout, 2005).

Summary
Recognition and compensation are two valuable tools for nurse satisfaction and retention. A clinical ladder program is one way that facilities can recognize and reward nurses. The ANNA Administration Special Interest Group has developed the Nephrology Nurses’ Clinical Ladder as a framework to help guide facilities in developing clinical ladder programs to meet their needs. This document is meant to serve as a template, allowing individual nephrology programs to tailor the clinical ladder program to meet their specific organizational structure and needs, thus allowing for recognition of professional role development in all nephrology arenas.

References
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Burrows-Hudson, S., & Prowant, B. (Eds.) (2005). Nephrology nursing standards of practice and guidelines for care. Pitman, NJ: American Nephrology Nurses’ Association.

Czerwinski, S., Blastic, L., & Rice, B. (1999). The synergy model: Building a clinical advancement program. Critical Care Nurse, 19(4), 73-77.

Drenkard, K. & Swartwout, E. (2005). Effectiveness of a clinical ladder program. Journal of Nursing Administration, 35(11), 502-506.

Gomez, N., Taylor, S., & Schardin, K. (1989). Nephrology nursing clinical ladder program. Pitman, NJ: American Nephrology Nurses’ Association

Kauffman, J., Glassberg, H., Charlebois, D., & Curtis, D. (2006). Clinical career ladder policy reference handbook. Charlottesville, VA: The University of Virginia Health System (UVHS) Professional Nursing Staff Organization.

Schmidt, L.A., Nelson, D., & Godfrey, L. (2003). A clinical ladder program based on Carper’s fundamental patterns of knowing in nursing. Journal of Nursing Administration, 33, 146-152.

Shapiro, M.M. (1998). A career ladder based on Benner’s model: An analysis of expected outcomes. Journal of Nursing Administration, 28(3), 13-19.