The learning process continued through the develop- ment, implementation, evaluation, and refinement phrases. Once the revised, reworded, peer-reviewed clinical ladder was implemented, the staff continued to support the pro- cess. (The clinical ladder appears in the Appendix of this article.) For advancement, both financially and within the institution, the clinical ladder incorporated educational re- quirements and a variety of avenues to achieve success. The various strategies included formal coursework as well as presenting, publishing, and attending occupational health nursing continuing education offerings.