The clinical nurse specialist (CNS) role is embedded deeply into clinical practice teams in hospitals and ambulatory settings.1 When the team achieves great outcomes, hopefully all members have access to a mechanism to highlight their successful contributions. In many settings, the CNS is the coach for a team of bedside nurses, works with multiple departments to streamline a patient care workflow, or collaborates with interdisciplinary colleagues to change practice. Yet, when project outcomes are presented, the CNS role is sometimes overlooked. The reasons for this may vary, but without a structured mechanism to describe specific contributions to the outcome, acknowledgments may not be distributed equally. Historically, CNSs have struggled to make their practice outcomes and positive impact visible.2 This is a difficult gap for any individual CNS to bridge. No one wants to be perceived as taking credit for the efforts of many in a team. The answer is to develop a process where all can be recognized both collectively and individually. One viable option is to develop an advanced practice clinical ladder.

A clinical ladder offers a mechanism to showcase individual professional outcomes. The design and scope will vary by organization, but the goal is always to increase nursing engagement and improve patient care outcomes. In some settings, the ladder includes only bedside nurses.3 In other settings, it is more inclusive and extends from the new graduate nurse to the advance practice registered nurse (APRN) with steps separated by education and expertise. In some organizations, the APRN ladder does not include the CNS.4-6 Overall, although many hospitals have a ladder for bedside nurses, professional ladders are less common for APRNs, including the CNS. Clinical ladders for other clinical professionals such as rehabilitation therapists, pharmacists, and social workers are rare.

Several theoretical frameworks are available to support clinical ladder development. These frameworks provide a lot of latitude to develop a structure that is most suited to the local environment. The seminal theoretical model on professional development in nursing was created by Patricia Benner7 in Novice to Expert. Benner eloquently demonstrated that nursing expertise positively changed over time with clinical practice exposure. Another model is the Magnet framework, which is extremely helpful for any organization that is, or aspires to become, Magnet designated.8 One key tenet of the Magnet model is "structural empowerment."8 This describes organizational structures that support safe patient care, evidence-based practice, and professional growth. All clinical ladders are examples of structural empowerment and are designed to promote nursing excellence at the individual level and within the organization. A clinical ladder for the CNS and other APRNs should be evidence based and include relevant competencies. For the CNS, this would include the APRN Consensus Model for Licensure, Accreditation, Certification, and Education9 and the CNS Core Competencies from the National Association of Clinical Nurse Specialists.10

Creating a clinical ladder requires a conviction that it is a beneficial addition to the organization. It also requires a willingness to negotiate with multiple stakeholders and to find compromise solutions. Whichever model is chosen, and whichever participants are selected, a lot of time will go into designing the theoretical framework, developing the criteria, and determining whether this will be a nursing ladder only or whether it will encompass other disciplines. Several years ago, when our organization developed their first clinical ladder for advanced practice roles, 4 representatives were selected to negotiate the details: 1 CNS, 2 nurse practitioners, and 1 physician assistant. I was the CNS on this team, and we met biweekly for several months to identify goals and hammer out the promotion criteria. From humble beginnings, this interdisciplinary clinical ladder has since grown exponentially.

Typically, clinical ladders require 1 or 2 narratives (exemplars) to demonstrate excellence in clinical practice. The candidate's portfolio will include other examples of professional leadership such as certification, publications, professional presentations, mentoring, and participation in multidisciplinary initiatives within the organization. Other requirements may include letters of support and volunteer activities in healthcare within and outside the organization. Our clinical ladder has 3 overarching domains: clinical expertise, institutional citizenship and leadership, and professional contributions. Some CNSs initially found it difficult to write about their positive contributions-claiming credit for work well done takes practice. However, this is now part of the CNS culture. Clinical nurse specialist engagement with the clinical ladder is an expected component of role advancement. A CNS will write exemplars to describe clinical impact and provide letters of support and other evidence as confirmation in each of the 3 domains.

Participation in a clinical ladder is a self-selecting self-empowerment step. The clinical ladder can help with CNS retention because it emphasizes professional growth. The essential baseline is clinical competency, and beyond that are criteria for clinical excellence. Other recognition opportunities come from presentations, research, publications, certification, and volunteerism. Most of all, advancement on the clinical ladder indicates the CNS is a lifelong learner, a clinical leader, and a role model.

The reason for any CNS to advocate for a clinical ladder within their healthcare environment is simple-it is a way to showcase CNS professional achievements and highlight CNS value to the organization. The creation of a digital portfolio encourages clinicians to retain examples of their work on quality improvement teams and other initiatives. From a personal perspective, I can attest to a feeling of great pride and personal satisfaction when I was promoted as a CNS on the clinical ladder.

Maintenance of the clinical ladder requires an organizational structure to evaluate portfolios and ensure fairness in the selection and evaluation process. These appraisal activities require financial support to underwrite the administrative infrastructure. Advancement steps on the ladder may include a financial benefit for participants, which may initially increase hospital costs. Potentially, if participation in the clinical ladder increases satisfaction and decreases staff turnover, this would result in a net savings for the organization. However, research in this area is weak.3

If there is not a clinical ladder in your organization, start a discussion with key stakeholders. If a clinical ladder for bedside nurses is in place (most common), inquire whether the CNS and other advance practice clinicians can adapt this structure to support their roles. Most of all, consider the clinical ladder to be a mechanism that allows all clinicians to promote their value to the organization through evidence-based practice, patient safety, leadership, and excellent patient care.

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