Establishing and Developing an Accessible and Inclusive Ambulatory Care Clinical Ladder Program

The ambulatory care clinical leadership of a large academic medical center with an expansive ambulatory care network established a clinical ladder for ambulatory care registered nurses in 2018. A committee consisting of managers and clinical directors gathered stakeholder buy-in to create and execute the first offering of the ambulatory care advancement program. At cycle completion, it was noted that the accessibility and ownership of the program remained in leadership’s hands. Believing “if you can see it, you can be it,” the committee engaged the newly minted ambulatory nurse IIIs to serve as program committee members, thereby bringing the voice of the ambulatory care nurse to the program decision-making table.

In reflection of the second cycle, it was identified that one of the eligibility criteria – national board certification – was a financial barrier for many nurses interested in the program. In response, the organization partnered with ANCC to institute the Success Pays® program. In removing the financial barrier, the number of certified nurses and therefore advancement eligible nurses increased. While certification is a standardized way for nurses to demonstrate a commitment to learning, quality care and competency in practice, the cost associated with taking a certification exam is exclusionary. By requiring certification and not supporting the cost of certification, only those that had the financial means could attain eligibility for advancement. While the intent was to hold a standard, the unintended effect was inequitable exclusion.

In continuing to strive for an equitable program, the third cycle taught us that mentorship, while a critical tool, could not be left up to chance. Without a standard mentor structure, those with existing connections, working in well-staffed clinics, or with previously existing relationships received beneficial counseling. Those without did not. To provide equitable access to the committee’s guidance, all applicants in the third cycle were assigned a committee member mentor and required to meet with that mentor. Through this update, the committee was able to support all applicants equitably.

Most recently, a learning needs assessment identified that nurses desired access to certification review instruction. While established programs already provided reimbursement for certification test review materials, few nurses were taking advantage of the benefit. In response, we contracted to host a live, free, instructor-led ambulatory care certification review course recognizing that some nurses are not able to shoulder the costs for review materials up front and many learners desire live, instructor-led learning. When we create programs to support, recognize, and promote nurses, we must make sure they are accessible and inclusive. We must tirelessly examine blind spots and continuously reimagine what is possible.