Clinical Ladder

Clinical Ladder Purpose

The MedStar St. Mary's Hospital Clinical Ladder provides an opportunity for advancement and leadership for nurses who provide direct nursing care to all patients. The Clinical Ladder allows for career progression by recognizing the professional nurse's clinical knowledge, competence and performance. Progression up the Clinical Ladder is an ongoing process, which requires formal documentation for advancement and/or maintenance.

The criteria used for advancement is based on four components: clinical practice, education, professional development and leadership. Nursing skills and knowledge are expected to increase both qualitatively and quantitatively as the nurse progresses through the clinical continuum. The depth of skill at each level increases as the nurse progresses through the system. Movement to a higher level builds upon skills demonstrated at previous levels. A nurse must verify that he/she is functioning at the current level of practice each year.

The Clinical Ladder is designed to:

  • Recognize and reward outstanding clinical expertise of staff nurses
  • Improve retention of nurses by providing opportunities for advancement at the bedside
  • Increase job satisfaction
  • Promote leadership
  • Improve patient care through personal growth and contributions to practice area
  • Encourage nurses to work towards their full potential

Clinical Ladder objectives include:

  • Recognition and reward for highly qualified nurses involved in direct patient care activities
  • Opportunities for advancement in clinical practice
  • Differentiation between levels of nursing expertise
  • Accountability to nurses for advancement
  • Stimulating individual professional development
  • Increased job satisfaction

Levels of Practice

The Clinical Ladder for registered nurses (RNs) is broken down into four levels. Each level provides recognition of professional preparation and expertise.

  • Registered Nurse I - Has recently graduated from nursing school, has less than one year of experience, or is returning to direct patient care after a prolonged absence. At this level, the nurse seeks guidance to integrate concepts, knowledge and skills necessary to provide patient care.
  • Registered Nurse II - Independently provides patient care through application of the nursing process and accepts accountability for the nursing care of assigned patients. At this level, the nurse is expected to identify and implement nursing interventions and evaluate the results. RN IIs should demonstrate leadership qualities. All nurses must attain and maintain quality performance at the RN II level.
  • Registered Nurse III - Coordinates and provides quality patient care through expert practice and application of the nursing process. Nurses at this level are expected to assume accountability for the nursing care outcomes for their patients and to actively participate in the development and ongoing evaluation of nursing practice on their units. These nurses provide clinical leadership by offering guidance, serving as a preceptor, and coordinating the healthcare team to meet individual patient/family needs. The RN III should be an active member of a committee.
  • Registered Nurse IV - This individual is sought out for guidance by staff and serves as a resource/role model for expert clinical practice on his or her unit. Nurses at this level take leadership in establishing the clinical practice standards on their unit and assume accountability for evaluating patient care outcomes based on these standards. Excellence is demonstrated in the nurse's ability to collaborate with the healthcare team and to plan and care for complex patient and family needs. The RN IV must have either a bachelor's degree in nursing or a master's degree/master's degree in nursing. The RN IV should also be an active member of a committee.