The Nurse Practitioner Clinical Ladder Program: A Journey to Professional Nursing Excellence

Quality Nurse Practitioner (NP) care delivery is associated with teambuilding, leadership, communication, clinical knowledge and skills, evidence-based practice, and quality outcome achievement (Cronenwett, 2012; Elliot, 2016). Yet, organizational structures and processes fostering continuous NP practice development have been infrequent (Elliot, Begley, Sheaf, & Higgins, 2016; Porter-O'Grady, 2011). In response to an organizational NP job satisfaction survey, the Nurse Practitioner Clinical Ladder (NPCL) program was developed to enhance professional excellence at a university affiliated medical center in the United States (Misener & Cox, 2001). Senior nursing leadership and administrative support were critical to the NPCL program development. The purpose is to describe professional practice journey and govenance needed for the NPCL program development, implementation, and evaluation.

Registered Professional Nurse (RN) clinical ladder program research has been associated with increased RN role development, job satisfaction, and decreased turnover (Adeniran, Bhattacharya, & Adeniran, 2012; Warman, Williams, Herrero, Fazelli, White-Williams, 2016). There was a dearth of knowledge concerning NPCL program development and outcomes. Benner's (2000) five levels of nursing practice provided a blueprint for behaviors and competencies associated with beginning, competent, proficient, and expert RNs. Benner's nursing practice levels were viewed within an advanced practice nursing lens and incorporated into the NPCL program.

Critical literature review, deliberation, and reflection by the NPCL committee members provided consensus for the NPCL program development. The organizational professional nursing practice model building blocks of caring, practice, collaboration, communication, professional development, and evidence-based practice were incorporated into the NPCL program. Three levels of NPCL practice were developed as a blueprint to foster NP role development, professional growth, evaluation, promotion, and rewards. The NPCL is reflective of the American Nurses Credentialing Center (ANCC) Magnet Model (2016), and the National Organization of Nurse Practitioner Faculties NP Core Competencies (NONPF, 2012). The NPCL practice domains and competencies included clinical practice and outcomes, academics and advanced nursing expertise, leadership and administrative support, professionalism, and community service.

Donabedian's Model of Quality Health Care (1988) guided the NPCL structure and process standards. The NPCL Structure Standard defined the program goals, NP practice levels, advancement opportunities, an incentive and reward system, and annual NP level performance appraisal components. The NPCL Process Standard described the NP promotional application requirements, professional portfolio elements, the NPCL review committee roles and responsibilities, the promotional decision-making, and the appeal process (Hespenheide, Cottingham, & Mueller, 2011). The NPCL outcome measures included the NP job satisfaction survey, job retention, and NP level promotional statistics. The need for an ongoing NP mentorship program and formalized orientation to the NP role were NPCL outgrowths. Ultimately, the NPCL can serve as a foundation for other nursing specialties to develop, implement, and evaluate their clinical practice. The NPCL program supports advanced practice nursing roles and competency development that can be translated at organizational, national, and global levels.