Abstract
Consistency of performance standards across multiple clinical settings is an essential component of a credible advancement system. Our advancement process incorporates a central committee, composed of nurses from all clinical settings within the institution, to ensure consistency of performance in inpatient, outpatient, and procedural settings. An analysis of nurses advanced during the first 18 months of the program indicates that performance standards are applicable to nurses in all clinical settings. The first article (September 2003) in this 3-part series described the foundation for and the philosophical background of the Vanderbilt Professional Nursing Practice Program (VPNPP), the career advancement program underway at Vanderbilt University Medical Center. Part 2 described the development of the evaluation tools used in the VPNPP, the implementation and management of this new system, program evaluation, and improvements since the program's inception. The purpose of this article is to review the advancement process, review the roles of those involved in the process, and to describe outcomes and lessons learned.
The Vanderbilt Professional Nursing Practice Program (VPNPP) is a performance-based career advancement system implemented in April 2000 at Vanderbilt University Medical Center. The goals of the program were to "create a program which would define and support professional nursing practice, to attract and retain clinical experts in direct care, to instill enthusiasm in nursing by recognizing and rewarding performance and to create aspirations for continued growth in nursing practice."
There are 4 levels of RN practice in the advancement process. The RN 1 is the novice or advanced beginner who is usually a new nurse. The RN 2 is a competent nurse who demonstrates mastery of technical skills and can competently care for all patients in the clinical area. All nurses are expected to advance to this level by the end of their first year of employment at Vanderbilt. Advancement beyond this level is the nurse's choice. The RN 3 is proficient, has in-depth knowledge of nursing practice, and is a role model and resource to others. The RN 4 is an expert who demonstrates a comprehensive knowledge base, mentors others, and is a leader in clinical and operational problem solving.
Every nurse at Vanderbilt is evaluated annually using the established performance evaluation system. A complete evaluation includes a self-review and feedback from managers, peers, and, in some instances, a physician. Evaluations also include a review of the nurse's documentation against a single standard. Data are collected from several perspectives over time to demonstrate consistency of individual nurse performance.
The evaluation process is used to monitor the performance progress and development of each nurse at Vanderbilt. Advancement from one level to the next requires that the nurse consistently demonstrate practice at the desired level in all key functions of the job description for a minimum of 6 months. Use of the evaluation data collection tools on a quarterly basis helps the nurse and manager to identify and plan for areas for growth and development. When a manager and new staff nurse agree that the evaluation validates consistent practice at an RN 2 level for 6 months, the manager advances the RN 1 to an RN 2 level. No external review is required.
It is through the evaluation process that nurses and/or managers most often recognize the readiness to advance to an RN 3 or RN 4 in the system. The need to ensure consistent application of the advancement process across the organization, as well as the economic impact of advancement to levels 3 and 4, required that the advancement process be more stringent at levels 3 and 4.
Advancement to RN 3 and RN 4 levels requires a central committee, as well as a manager's review of the nurse's performance. The central committee is used as the ongoing interrater review process within the organization. The committee evaluates nurses across the organization against a single standard and a single interpretation of the standard. The process eliminates variability in understanding and recognition of expert nursing practice that may exist among individual managers.
To advance to an RN 3, the nurse must accomplish 3 things. First, the RN must receive manager endorsement, as demonstrated by a satisfactory performance appraisal at the RN 3 level. Second, the nurse must secure endorsement from a healthcare team professional in a discipline other than nursing. Finally, the nurse must provide written examples that document his or her practice at an RN 3 level or participate in a structured interview with members of the central committee.
To advance to an RN 4, the nurse must receive manager endorsement, as demonstrated by a satisfactory performance appraisal at the RN 4 level. As with advancement from RN 2 to RN 3, the nurse must receive endorsement from a healthcare team professional in a discipline other than nursing. The nurse must also participate in a structured interview with central committee members.
When the professional nurse determines that he or she is ready to pursue advancement, there are several resources available. Those resources include VPNPP resource manuals, which are available in all practice areas. These manuals describe the program, the performance requirements, and the process of advancement. All required tools are included in the resource manual. All of the information in the resource manuals is available on the Vanderbilt human resource Web site as well. Nurse managers, members of the VPNPP Central Committee and Steering Committee, and ad hoc area representatives are all available to assist the nurse in successfully advancing to his or her desired level. A VPNPP e-mail address provides all staff and managers with access to the project manager and rapid response to questions they may have.
Once the manager has completed the performance evaluation and the RN has acquired the healthcare team endorsement and completed the optional written examples, the manager submits the complete portfolio to the VPNPP project manager. The portfolio includes all completed evaluation data collection tools. As described in the previous article, the data collection tools are 4 documentation audits, the manager/assistant manager/charge nurse feedback tool, the peer feedback tools, and physician feedback tools where applicable. The manager also includes the annual evaluation summary sheets that show the nurse's scores in each key function and the healthcare team endorsement tools. If the RN who is advancing to RN 3 does not choose to be interviewed, written examples of practice at RN 3 must be included.
On receipt, the VPNPP project manager reviews the portfolio to ensure that the packet is complete. The portfolio is then assigned to 2 central committee members for review. The central committee members complete a detailed packet review, searching for examples of performance at the requested level. If the candidate is an RN 3 candidate who has not opted for an interview, the central committee members use the information in the packet exclusively to determine whether the candidate is eligible for advancement. If the candidate is to be interviewed, the interview time is scheduled.
The interview with the candidate is an opportunity for the RN to tell his or her stories about patient care that exemplify how his or her performance meets the established criteria. All candidates have access to standardized interview questions and the response criteria before the interview. Questions range from discussion of complex patient situations to challenging patient/family education situations to cost-effective practice and research applications.
Throughout the interview process, central committee members listen for examples of advanced level performance requirements. They probe for more information as necessary. The goal of the interview team is to have enough information to recommend the candidate for advancement and then defend that recommendation to the full central committee membership. The central committee interview team sees itself as an advocate for the candidate at the central committee meetings. The interview is the opportunity for the professional nurse to elaborate on why and how his or her actions consistently demonstrate practice at the level of advancement desired.
Once the interview is complete, the 2 central committee members confer to form a recommendation and clarify the examples they will use to defend the candidate at the central committee. When the central committee convenes, it uses examples of how the nurse meets expected performance criteria and presents the information. The central committee members again try to establish that the candidate meets the requirements and demonstrates consistent performance equivalent to all RNs at the requested level across the organization. Once all questions are answered, the committee votes on the advancement of the candidate, and the candidate is either recommended for advancement or a remedial plan is established.
The central committee recommendation is made to the chief nursing officer, who then notifies the candidate of successful advancement. The successful candidate receives the recognition of advancement to the level desired, as well as compensation. All nurses entering the Vanderbilt system are quoted salaries within either the general care or the critical care RN 2 salary matrix. The matrix adjusts salaries and establishes an individual nurse's base rate based on his or her years of experience. The inexperienced new nurse, RN 1, receives the first step of the RN 2 matrix for his or her entry salary. Annually, but independent of the VPNPP system, each RN receives a base rate increase that is commensurate with the results of his or her performance review. When an RN achieves promotion to the RN 3 level, he or she receives $2.00 per hour in addition to his or her base salary. The RN 4 receives $3.00 per hour in addition to his or her base rate.
The manager must then assess whether the candidate continues to meet performance expectations at the recognized level and hold the staff member accountable. This is accomplished through the ongoing evaluation process described in part 2 of this series.
If an RN 3 or RN 4 transfers to another department, he or she has 12 months to demonstrate performance at the designated level, or he or she may choose to transfer as an RN 2 and take a decrease in pay. The ongoing performance appraisal process verifies and continually monitors that performance remains at the designated level.