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View from a Clinical Ladder

Vol. 11 •Issue 8 • Page 24
Eye on Leadership

View from a Clinical Ladder

"Surround yourself with the best people you can find, delegate authority and don't interfere."
– Ronald Reagan

Respiratory care department managers need to find innovative methods to reward staff members who consistently set the bar for others to reach. One way is to establish a clinical ladder program, which provides respiratory therapists who possess advanced clinical knowledge and leadership skills to be promoted through other means than management.

Hopefully, this will be reflected in improved patient outcomes and allow your staff increased autonomy and accountability while they remain in direct patient care roles. All these factors will promote staff retention and satisfaction, help to expand RTs' role in your facility, and bring recognition for clinical proficiency and expertise.

Each institution may have a different purpose for implementing a clinical ladder. Consider the following reasons:

• to identify clinical activities, roles and behaviors for patient care delivery

• to establish clinical levels of performance on a continuum of expertise to meet requirements of patient care

• to identify behavioral expectations (criteria) for each advancement level

• to establish a system for clinical therapist performance evaluation and advancement, which incorporates peer and management review.


Establishing a program can be very rewarding, and it will prove its worth to managers on many fronts. But before you pursue an advancement program, a foundation must be laid incorporating a motivator (yourself), a monitor (an active council structure), facilitators (clinically advanced personnel), and recipients (new employees). The number of council members can vary depending on the size of your .department. Elect a chairperson (preferably not the manager) and a secretary.

Once the committee is formed, it's important to define its function. Members should work together to create, maintain and evaluate the clinical advancement program. They should communicate information about the program to all RTs and, in turn, relay the staff's ideas, concerns and comments about the program to the committee. You must have staff "buy in" to develop and maintain your particular model. Most institutions have a nursing ladder in place, so consult with your colleagues when formulating your vehicle.

The next step is to decide exactly what your levels of advancement will be and who will be eligible for that advancement. To keep things simple, it's recommended that only three levels be established. (See Table.) Only registered therapists who are members of the American Association for Respiratory Care should be your candidates because they have achieved the highest credential in their field (other than specialty exams), and to better themselves (other than management), ladders are the only venues. Also stipulate whether new hires, rehires, full-time employees or part-time employees are eligible.


The committee is responsible for establishing the application process. Candidates should be required to submit an application form, a current resume, a recent yearly evaluation, a letter of recommendation from a co-worker, and a statement of justification. The statement of justification needs to include an explanation of why this individual desires promotion. The statement also should cover details of his or her background, expertise, strengths and weaknesses. Most importantly the candidate should state his or her future goals.

When evaluating an application, the committee should ask themselves whether the candidate demonstrates professionalism and leadership. Evidence of both these qualities must be present. Consider the following questions:

• Is the candidate pursuing formal education in a health care-related field?

• Does she possess advanced credentials?

• Has she conducted an organized education program for hospital staff?

• Has she produced literature for publication?

• Is the candidate actively involved in departmental- or hospital-based committees?

• Does she invite dialogue and facilitate effective communication within and between departments?

• Does she motivate and challenge others by displaying energy and enthusiasm in creating a positive work environment?

• Has she developed discharge plans, care plans or policies and procedures?

• Does she serve willingly as a mentor for new employees or students?

The committee also should weigh heavily letters of recommendation from the candidate's co-workers. Take into account how long and in what capacity the colleague has worked with the applicant. Look for specific examples of the applicant's ability to provide patient and family care, including biological, physiological and psychosocial aspects. The letter will give you insight to the applicant's communication style with patients, families, colleagues and other health care professionals.

An option you might want to incorporate is the right to actually interview the applicant. Perhaps portions of her packet are inadequately explained or documented. This would give you the chance to clear up those details.

Once the application has been reviewed, it's time to make a decision. All committee members should sign letters of confidentiality, which ensures a safe environment for all to speak freely. A unanimous consensus must be reached.

It's important that the committee awards promotions to candidates who are well-rounded and excel in all areas. For instance, a candidate could be a wonderful bedside caregiver but lack leadership skills. This person shouldn't be granted advancement.

Implementing a clinical ladder program has many benefits. Encourage your staff to reach a little higher.

Edens is clinical education coordinator, respiratory care division, Cincinnati Children's Hospital.

Table. Example of Advancement Levels

Respiratory Therapist I

• Competent in patient assessment, problem solving and treatment implementation

• Recognizes the need for effective interpersonal communication and utilizes available resources to broaden clinical skills and enhance professional growth

• Able to establish priorities

• Participates in continuing education and assists in the educational process of students and orientation

• Certified, registered or registry eligible by the National Board for Respiratory Care (NBRC), licensed by the state, encouraged to become a member of the AARC

Respiratory Therapist II

• In addition to the responsibilities of a Respiratory Therapist I, demonstrates expertise in areas of clinical practice and is utilized as a role model and a resource person within the .respiratory care department

• Uses his/her experience and increased knowledge base to guide others in problem solving, time management and prioritization.

• Acts as a patient care advocate

• Applies knowledge to analyze situations that could otherwise be potential problems and utilizes analytical thinking in all areas of clinical practice

• Projects a positive professional image and works to help others identify and meet their learning needs

• Participates in continuing education not only by attending, but developing in-services or authoring education material

• Actively involved with a committee on his/her unit or the respiratory care department as a member and/or co-chairperson

• Consistently evaluates and strives to improve the standard of care

• Registered by the NBRC, licensed by the state, member of the AARC

Respiratory Therapist III

• In addition to the responsibilities of a Respiratory Therapist I and II, serves as a role model and a resource person within his/her unit, the respiratory care department, hospital and the community

• Involved with continuing education by developing and/or presenting programs for peers

• Effectively contacts appropriate resources to resolve a patient problem

• Acts as a unit leader who has earned the trust of peers and managers and has achieved recognition for clinical excellence

• Demonstrates involvement in one or more of the following: ongoing research, interdisciplinary task forces, professional organizations, performance improvement

• Registered by the NBRC, licensed by the state, member of the AARC


Hello. I am really interested in implementing a career ladder at the facility I work at. I am a new RRT, 3 years in the field, an feel like it is imperative to my profession to have structured goals and continuing advancement opportunities. Currently, the only long term goal is management. Well, that route is definitely not for everyone. I would love information on how and where to start to try and get a career ladder for my department. I have asked my manager and he always comes back with "I have tried and got shot down". That is not acceptable to me. I love my chosen career path and want to challenge myself, as well as my peers, to build my knowledge and improve the care I give. I want to teach and mentor those that will let me. Any information you have to offer is greatly appreciated. Thank you for your time.
Amanda Nunez, RRT

Amand Nunez,  RRT,  Texas Health Resources SouthWest HospitalAugust 19, 2014
Fort Worth, TX


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