Helping nurses climb the clinical ladder

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Professional development 

After reading this article, you will be able to:

  • Identify barriers to applying for clinical advancement
  • Develop strategies to facilitate clinical ladder advancement

Does your organization have a process for clinical advancement? Do many nurses pursue advancement, or do they feel there are barriers? 

At Yale-New Haven (CT) Hospital, Pina Violano, MSPH, RN-BC, CCRN, PhD(c), was concerned that too few nurses took advantage of the clinical advancement program offered by her organization. Violano is now the injury prevention coordinator for the trauma department, but at the time she was a clinical nurse educator in the Center for Professional Practice. She says only 50% of nurses participated in the program and less than 0.2% achieved Clinical Nurse IV, the highest level of practice (Pellico & Violano, 2010). As a result, she felt there was a serious problem. 

“As an educator, I was concerned that so few nurses were completing the application process to advance clinically,” says Violano. “I believed that nurses needed a voice to prepare themselves to attempt clinical advancement.” 

She realized that nurses needed help preparing their application portfolios for advancement, which consist of a letter of intent, clinical narrative or exemplars, curriculum vitae (CV), a self-evaluation, and clinical practice goals. A completed portfolio is submitted to a formal committee that meets four times per year to review applications. 

For nurses to begin the advancement process, the first step is to inform their manager of their plan to apply by submitting a letter of intent. After the manager gives the okay, nurses prepare the portfolio. 

“I found that many nurses were intimidated by the process,” says Violano. So she developed a formal, daylong class where nurses could gather and work on the application process.  

Class content

The class size was limited to 12, allowing for individualized attention and small group discussions. It was also the maximum number of people who could be accommodated in the computer lab. 

“It is important that all participants have computer access since they actually work on writing letters, CVs, etc., in the classroom setting,” says Violano. “The goal is to have as much of the application portfolio completed by the end of the class as possible. In fact, about one-third of the class is generally able to complete their entire portfolios by the end of the day.”

Before the nurses could work on writing their portfolios, though, they needed help with computer and writing skills. “I found that even though we are extremely electronic in our organization, nurses still lacked typing and writing skills,” says Violano.

The class also had in-depth discussions on written and verbal communication skills. They reviewed tips for communicating with managers as well as how to compose a letter of intent. Several templates were presented to help participants formulate their letters. (See p. 3 for two examples of letters of intent.)

CV development

During the class, Violano likened writing a CV to writing a storybook of participants’ professional careers. A template was developed so that nurses simply had to fill in critical information, individualizing the template to their own careers. 

Nurses needed a lot of help with identifying activities and accomplishments to include in their CVs. “They tend to underestimate the skills and knowledge they possess,” Violano says.

Clinical narratives and self-evaluations

Although templates were useful for some aspects of portfolio development, they were not suitable for clinical narratives (exemplars) or self-evaluations. Exemplars require nurses to tell a story about their clinical decision-making and collaboration and how they positively affected a patient. 

Nurses, in general, are not accustomed to praising themselves. Violano used the book Women’s Ways of Knowing: The Development of Self, Voice, and Mind to help participants find their professional voices and express themselves in writing. The concept of finding one’s voice includes learning to express oneself, taking credit for successes, exploring areas for improvement, and identifying future goals and ambitions. The classroom setting provided a safe, supportive environment in which nurses could create their exemplars and reflect on their nursing practice. 

In the next segment of the application, the self-evaluation, nurses must reflect on the current state of their practice and areas where they can improve. The candor and thoughtfulness of these reflections allows the clinical advancement committee members to gain insight into applicants’ attributes and self-awareness. 

Identifying professional goals

An important step in assembling a portfolio, is to identify measurable professional goals. Violano did not simply help write these goals; she also provided resources to assist nurses in meeting them.

“If someone says she wants to go back to school, I make it a point to have college catalogs available for them to look at,” she says. “Some may say they want to become more involved in professional associations, so I make sure that I have information about associations available.”

About 87% of the nurses who attended the classes have advanced on the clinical ladder. They report that having a nurturing environment to work on their portfolios was a great benefit.

Clinical advancement is an important retention tool. But, Violano points out, the real impetus of this program is the professional development of staff.


Belenky, et al. (1986). Women’s Way of Knowing: The Development of Self, Voice, and Mind. New York: Basic Books, Inc. 

Pellico, L.H., & Violano, P. (2010). “Creating a Room of Our Own.” Journal for Nurses in Staff Development 26(3): 104–107.

Two examples of letters of intent to be used as templates

September 15, 2010

Susie Smith, RN

Patient Services Manager

Major Medical Center

One Main Street

Anywhere, USA 01111

Dear Susie,

I hope this finds you well. Over the past year, the unit has made numerous positive changes in our structure benefiting patients and staff. I feel honored to have been included in developing and implementing change.   

As my annual performance review approaches, I would like to formally apply for advancement in the clinical ladder to Clinical Nurse IV. With your support and encouragement, I began this process in January of this year. I have completed the required clinical hours and prerequisites for advancement and am excited to submit my portfolio.  

Thank you for all your feedback, advice, and time you have given to promote my leadership development and personal potential. I am in your debt.

Best regards,

Nancy Nurse, MS, RN-BC, CCRN

September 15, 2010

Cherry Ames, RN

Patient Services Manager

Major Medical Center

One Main Street

Anywhere, USA 01111

Dear Cherry,

This letter is to inform you that I, Nancy Nurse, intend to apply for advancement from Clinical Nurse III to Clinical Nurse IV.  

After almost five years of practice in the pediatric ICU at Major Medical Center, I feel it is an appropriate time to seek advancement.  

If you have any questions or comments regarding my application for advancement, please feel free to contact me. I appreciate your time and your support.


Nancy Nurse, MS, RN-BC, CCRN

Source: Pina Violano, MSPH, RN-BC, CCRN, PhD(c).