Featured speaker Julie Holland, DNP, RN, NE-BC Associate Vice President, System Clinical Effectiveness, Texas Health Resources
Featured speaker Shelby Do, DNP, RN, NEA-BC, CCRN , Clinical Excellence Project Manager, Department of Nursing Professional Practice, Texas Health Resources
Moderated by Larissa Africa, MBA, RN, CENP, FAONL, FAAN, Vice President, StaffGarden by Ascend Learning
For today’s Chief Nursing Officers (CNOs), professional development has become a workforce lever that directly affects retention, engagement, accreditation readiness, and financial performance.
At a recent American Organization for Nurse Leadership (AONL) Sunrise Session, leaders from Texas Health Resources (THR) shared how modernizing a traditional clinical ladder into a digital, system‑level program helped the organization nearly double participation, demonstrate consistently lower turnover among ladder nurses, and realize more than $160 million in workforce cost avoidance over two years.
THR’s Nursing Career Advancement Program (NCAP) fundamentally changed how leadership viewed professional development, as NCAP “shifted from being perceived as a cost center, and instead as a strategic workforce investment,” explained Shelby Do, DNP, RN, NEA‑BC, CCRN, Clinical Excellence Project Manager in the Department of Nursing Professional Practice at Texas Health Resources.
THR’s NCAP showcases firsthand how the clinical ladder can become a core component of healthcare organizations’ financial performance and excellence metrics.
Originating in the 1970s and grounded in Patricia Benner’s Novice‑to‑Expert model, Clinical Ladder Programs (CLPs) were designed to recognize bedside expertise, support professional growth, and reinforce quality, safety, mentorship, and evidence‑based practice— without requiring nurses to move into management. In principle, these goals remain just as relevant today, given ongoing staffing instability and rising labor costs.
The challenge, as many CNOs know firsthand, is execution. Paper-based ladders create significant operational friction. Nurses and leaders face high, episodic workloads as documentation is recreated at submission time. Evidence standards vary across units and facilities. Additionally, governance becomes complex, and financial sustainability of these programs can be difficult to maintain.
This financial pressure often causes ladders to be paused or modified — despite their workforce value — "forcing organizations to balance fiscal responsibility with long-term stability,” explained Larissa Africa, MBA, RN, CENP, FAONL, FAAN, Vice President, StaffGarden by Ascend Learning.
At THR, scale amplified these challenges. The system includes 23 hospitals across North Texas, more than 10,000 registered nurses, and a mix of Magnet®‑designated facilities, Pathway to Excellence®‑designated facilities, and community hospitals of varying size.
Before digitization, the Nursing Career Advancement Program (NCAP) relied on a tiered RN III-RN VI structure supported by entity-level nurse peer review committees, with final approvals moving through Chief Nursing Officers and a system committee. Julie Holland, DNP, RN, NE-BC, Associate Vice President of System Clinical Effectiveness at Texas Health Resources, described a process that involved leaders “literally signing off on paper.”
The question for leadership was straightforward but difficult: how could THR maintain bedside expertise, grow participation, and demonstrate measurable value without increasing administrative burden or financial risk?
THR’s leadership team approached digitization with clear expectations. After reviewing the literature comparing paper and digital ladders, they concluded that digital platforms do not independently cause retention and that technology cannot replace governance, coaching, or leadership accountability. Holland emphasized this distinction clearly, noting that “technology is an enabler, not the intervention.”
What digitization does change is the feasibility of scale. Compared with paper‑based programs, a digital clinical ladder supports ongoing documentation rather than episodic submissions, improves participation by lowering process friction, and provides real‑time visibility into nurse progress. Automated workflows and reporting reduce manual effort, while longitudinal records preserve professional practice evidence over time. For THR, the goal was to reduce friction, improve transparency, preserve rigor, and enable consistency across facilities while remaining fiscally responsible.
Adoption required meaningful investment in both training and change management. Do emphasized that StaffGarden provided “really helpful training for end users and committees processing portfolios,” while leaders were trained as reviewers to standardize expectations across the system.
Once nurses adjusted to digital portfolios, there was little appetite to return to paper. Leaders observed strong resistance to going back, and nurses reported enjoying the process. As Do explained, the platform made portfolios “much more accessible and immediate,” allowing nurses to update and modify them continuously rather than waiting for an annual submission window.
THR took a gradual, intentional approach. The initial contract began in 2019, when participation hovered around 14%. Program build and systemwide rollout followed in 2020 and 2021. By 2023, paper portfolios were fully retired, and by 2025, systemwide participation had doubled to approximately 30%.
Participation growth became one of the clearest signals that the program was working. By 2025, all 18 participating hospitals outperformed non-participating hospitals in ladder adoption. This shift mattered not just in percentage terms, but in what it represented.
Nurses felt more involved and more heard. As Do noted, participation increased in part because now, “nurses feel like they have a voice.”
For CNOs, this matters because higher participation translates into greater engagement in quality improvement, evidence‑based practice, mentorship, and education. It also provides system‑level visibility into professional contributions that often go unseen when development programs are inconsistently documented.
Beyond participation, digitization significantly reduced administrative burden, particularly around Magnet® reporting. With demographic data integrated into the platform, THR can use this data directly for DDCT reporting. Do described this shift as “a huge burden off our shoulders,” noting that leaders can now directly download reports, rather than compiling manually.
The platform became what Do referred to as “our source of truth for data, because it communicates with our HR system. Now we can see demographics and participation at the system-level, which is important for Magnet® reporting.” Smaller facilities, in particular, also benefitted from improved inter-rater reliability and greater consistency in standards and language across hospitals.
Reducing administrative friction made participation realistic and accessible, especially for bedside nurses: “For those using the digital platform, their confidence as bedside nurses increased,” Do added.
As a result, THR has already achieved 70% of target education and certification tracking metrics for this year, with Do noting that the new system is performing “much better than a call sheet or pushing to get the information from individual managers.”
When THR compared turnover data between ladder and non‑ladder nurses across multiple years, ladder participants demonstrated consistently lower turnover rates than their non‑ladder counterparts, even as the size of the ladder population grows.
o In 2023, ladder nurses had a 3.3% turnover rate, compared with 11.3% for non‑ladder nurses.
o In 2024, ladder turnover rose modestly to 7.2%, while non‑ladder turnover remained higher at 8.7%.
o In 2025, ladder turnover declined again to 6.0%, while non‑ladder turnover increased to 11.3%, further widening the retention gap.
The turnover gap between ladder and non‑ladder employees is persistent. Lower ladder turnover holds even as participation increases, suggesting the program scales without eroding its strong retention impact.
While leaders were careful not to claim that ladders alone caused retention, the correlation was strong enough to inform ongoing workforce strategy.
As Do put it plainly, “when nurses feel invested in, they stay.” The ladder provided not just recognition, but visible reinforcement that professional growth at the bedside mattered.
From a financial perspective, THR deliberately avoided positioning NCAP as a revenue‑generating initiative. Instead, leadership framed the impact in terms of cost avoidance— they compared non‑ladder turnover costs against the total cost of the clinical ladder program, including incentives and management costs.
Using this calculation, THR identified more than $70 million in cost avoidance in 2023 and more than $90 million in 2024— totaling more than $160 million in savings over two years.
This framing allowed NCAP to be discussed credibly at the executive level, reinforcing Do’s point that the program had shifted from a perceived expense to a strategic investment.
In 2025, THR extended digital professional development by launching a system‑level peer feedback process using the same platform. In doing so, the organization reinforces professional practice, reflection, and accountability while also supporting the Magnet® Structural Empowerment domain.
According to Do, “using a system-level platform allows us to include system-level peer feedback processes” consistently across facilities. Nurses first completed self‑assessments, then selected their peers, and managers were then automatically assigned through the HR feed.
Early outcomes included improved documentation readiness for site visits and greater clarity around where feedback lived. Importantly, leaders like Do report that peer feedback became “more of a professional development opportunity and not just a checklist,” reinforcing reflective practice rather than compliance alone.
As THR looks ahead to launching the second round of the peer feedback process in StaffGarden, Do added that “it’s so easy to be able to pull information out of the office, bookmark it, and show the appraisers exactly what they want to see. We’re very grateful for that process and how easy it is.”
Looking ahead, THR is exploring expansion of ladder frameworks beyond nursing, responding to “interest coming from allied health, PTs, seeing the success of the nursing program and wanting to replicate that,” Do stated.
The system is also working toward deeper analysis linking ladder activity to patient outcomes, quality improvement, and evidence‑based practice, while continuing to refine cost‑avoidance modeling. As Do emphasized, clinical ladders are no longer viewed solely as professional development programs, but as a core component of enterprise workforce strategy.
Texas Health Resources’ experience reinforces several lessons for nursing leaders:
o Participation growth is a leading indicator of engagement.
o Retention differences between ladder and non‑ladder nurses are meaningful.
o Financial impact resonates most when framed as cost avoidance rather than promised ROI.
o Digital clinical ladders can enable rigor, equity, and scale, but leadership commitment and governance are the bedrock.
o The real opportunity lies in connecting professional practice to broader organizational strategy.
As Africa summarized, “professional advancement programs are the way to remain competitive in today’s healthcare environment. We must implement innovative strategies that not only retain our current workforce but also attract new talent.”
CLPs are powerful tools in driving nursing retention and job satisfaction. When designed effectively, they recognize expertise, support professional growth, and reinforce nurses’ value to the organization without requiring them to leave the bedside.”
But to fully realize the impact, concluded Africa, “we must evolve in how these programs are delivered. Transformative digital solutions that streamline and simplify the digital ladder process removes the administrative burden and improves accessibility, and ultimately modernizing the clinical ladder strengthens engagement, retention, and our ability to build and resilient and future-ready workforce.”
If you’re exploring how to modernize your clinical ladder, reduce administrative burden, and make professional practice data work harder for your organization, our team is here to help.
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