How AdventHealth's Clinical Ladder Programs Flipped the Script on Nurse Turnover

Clinical ladder programs have great potential for reducing turnover and increasing engagement, says this CNE.

The impact of nurse turnover is no secret to CNOs.

When health systems lose nurses, it has sweeping effects on the organization's culture and budget. The average cost of turnover for a single bedside RN is $61,110, which stacks with the cost of overtime labor or contract labor to help cover the care gap. On top of that, it can take several weeks or even months to fill a vacancy in the nursing workforce.

The short- and long-term implications of high turnover are similar but with differing degrees, according to Trish Celano, system chief nursing executive and associate chief clinical officer at AdventHealth.

"Nursing turnover just leads us to shortages of [nurses], to increased stress, increased team member burnout, [and] workforce burnout," Celano said. "At the end of the day it impacts patient experience as well as clinical outcomes."

Targeting turnover

To combat turnover at AdventHealth, Celano and the other leaders at the organization developed a clinical ladder program for nurses.

Before the program was launched in 2021, the health system's turnover rate sat at 31.5%, and the financial implications were significant, Celano explained.

"That's just the financial implications, [and that] is just touching the surface," said. "The impact to care delivery [is] where we see some opportunities when you talk about nursing turnover."

The clinical ladder program was implemented at six out of AdventHealth's 57 hospitals at the beginning before it was launched electronically across all facilities in 2022, Celano said. The clinical ladders help create a structure for nurses to continue to advance.

"We were hearing from our bedside nurses quite loudly that it seemed to them that nurses, in order to advance in the organization, needed to get away from the bedside," Celano said. "[That's] not something that you want to hear as a chief nursing officer."

After receiving that feedback and looking at the evidence from other Magnet organizations, Celano explained that it became clear that the organization needed a program to help make advancement pathways possible and visible for bedside nurses.

"To have a nurse that has 10 years of experience is like having a block of gold," Celano said. "So, when those nurses leave the bedside for other roles, simply because they don't feel like they're valued and they don't feel like all of their experience and knowledge and what they bring is being appreciated or recognized, we knew that was something we needed to jump on and address."

Following the implementation of the program, AdventHealth's total turnover for RNs is 14.8%, according to Celano. Full and part time nursing turnover is at 12.4%, and nurses who are participating in the clinical ladder program are at less than 6%.

"We couldn't be more pleased," Celano said, "and if anything, we're just saying 'why didn't we take this company-wide sooner,' but everything in due time."

There have also been significant financial savings as a result of reduced turnover, which Celano emphasized is just the tip of the iceberg.

"What drives us is the engagement of our frontline team members," Celano said. "We're almost at 80% engagement for our RNs, which is also industry leading."

Additionally, AdventHealth was the first in the U.S. to include an element of self-care in the clinical ladder program, according to Celano. 

"At the end of the day if our nurses don’t "feel whole" how are they going to provide "whole person" care to our patients?" Celano said. "For us at AdventHealth that is really our signature focus, to provide whole person care, and we realized we were not helping our own bedside staff to do that so we needed to address it."

Why a clinical ladder?

Clinical ladder programs are strong retention tools because they affirm bedside nurses, Celano emphasized.

"Our practice councils were telling us that a nursing professional ladder was what they wanted and what they felt like would give them the recognition as well as the ability to continue to advance without having to leave the bedside," Celano said.

The frontline nurses at AdventHealth were essential in making the decision to implement the program.

"Your frontline staff and nurses know what they need, know what they want, [and] know what's best for patients," Celano said. "When we ask them to solve our problems, they get solved more quickly and they are generally much more accurate."

For CNOs who might want to implement their own clinical ladder programs, Celano recommended launching the program electronically.

"No more binders and paper, the electronic version is much easier to launch and to maintain because it's got to be evaluated every year [to make sure] those nurses are still engaging and performing," Celano said. "Whether they're getting nationally board certified or they're a subject matter expert in pain management, there are a number of different ways that they can earn points within the ladder to progress based on their experience."

Celano also emphasized that AdventHealth is happy to share successes and best practices.

"We're happy to share that because as a nurse of 32 years, the best thing I can hope to do is improve the environment for bedside nurses because that directly improves the environment for our patients," Celano said.